U.S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL

FORT SAM HOUSTON, TEXAS 78234-6100

THE GENITOURINARY

SYSTEM I

SUBCOURSE MD0579 EDITION 100

DEVELOPMENT

This subcourse is approved for resident and correspondence course instruction. It
reflects the current thought of the Academy of Health Sciences and conforms to printed
Department of the Army doctrine as closely as currently possible. Development and
progress render such doctrine continuously subject to change.

ADMINISTRATION

Students who desire credit hours for this correspondence subcourse must enroll in the
subcourse. Application for enrollment should be made at the Internet website:
http://www.atrrs.army.mil. You can access the course catalog in the upper right corner.
Enter School Code 555 for medical correspondence courses. Copy down the course
number and title. To apply for enrollment, return to the main ATRRS screen and scroll
down the right side for ATRRS Channels. Click on SELF DEVELOPMENT to open the
application; then follow the on-screen instructions.

For comments or questions regarding enrollment, student records, or examination
shipments, contact the Nonresident Instruction Branch at DSN 471-5877, commercial
(210) 221-5877, toll-free 1-800-344-2380; fax: 210-221-4012 or DSN 471-4012, e-mail
accp@amedd.army.mil, or write to:

NONRESIDENT INSTRUCTION BRANCH

AMEDDC&S
ATTN:

MCCS-HSN

2105 11TH STREET SUITE 4191

FORT SAM HOUSTON TX 78234-5064

Be sure your social security number is on all correspondence sent to the Academy of
Health Sciences.

CLARIFICATION OF TERMINOLOGY

When used in this publication, words such as "he," "him," "his," and "men" 'are intended
to include both the masculine and feminine genders, unless specifically stated otherwise
or when obvious in context.

USE OF PROPRIETARY NAMES

The initial letters of the names of some products may be capitalized in this subcourse.
Such names are proprietary names, that is, brand names or trademarks. Proprietary
names have been used in this subcourse only to make it a more effective learning aid.
The use of any name, proprietary or otherwise, should not be interpreted as
endorsement, deprecation, or criticism of a product; nor should such use be considered
to interpret the validity of proprietary rights in a name, whether it is registered or not.

TABLE OF CONTENTS

Lesson

Paragraphs

INTRODUCTION

1 ANATOMY

AND

PHYSIOLOGY OF THE GENITOURINARY

SYSTEM ........................................................................................... 1-1--1-9

Exercises

2 PHYSICAL

ASSESSMENT

OF THE GENITOURINARY

SYSTEM ........................................................................................... 2-1--2-4

Exercises

URINARY SYSTEM DISEASES/DISORDERS

Section

I Urinary

Tract Infections..............................................

3-1--3-4

Section

II Kidney

Diseases and Disorders .................................

3-5--3-13

Section III Management of Kidney Diseases .............................. 3-14--3-15

Section

IV Disorders

of the Ureters.............................................

3-16--3-17

Section V

Disorders Involving the Bladder ................................. 3-18--3-20

Section

VI Disorders

of the Urethra.............................................

3-21--3-22

Section VII Injuries to Organs of the Genitourinary System ..........

3-23--3-26

Section VIII Drug Therapy for Genitourinary Disease/Disorders ....

3-27--3-34

Section

IX The

Effects of Aging ..................................................

3-35--3-37

Exercises

4 URINARY

CATHETERIZATION....................................................... 4-1--4-8

Exercises

MD0579 i

CORRESPONDENCE COURSE OF

THE U.S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL

SUBCOURSE MD0579

THE GENITOURINARY SYSTEM I

INTRODUCTION

Today,

than 8 million Americans are affected by renal-related diseases. This

fact suggests that you will probably deal with renal patients often. Add to this the complex
human reproductive system by which a single cell duplicates its genetic material, allowing
an organism to grow and repair itself. To give patients with problems in either or both
systems the best possible care, you need to know normal anatomy and physiology of the
systems, specific disorders in each system, assessment methods, and treatments.
Regardless of the cause or the duration of the problem, it is important for you as a combat
medical specialist to be able to recognize and treat/refer for treatment any individual with
genitourinary system difficulties.

Subcourse Components:

The subcourse instructional material consists of four lessons as follows:

Lesson

Anatomy

and

Physiology of the Genitourinary System.

Lesson 2, Physical Assessment of the Genitourinary System.

Lesson 3, Urinary System Diseases/Disorders.

Lesson

Urinary

Catheterization.

Here are some suggestions that may be helpful to you in completing this

subcourse:

--Read and study each lesson carefully.

--Complete the subcourse lesson by lesson. After completing each lesson, work

the exercises at the end of the lesson, marking your answers in this booklet.

--After completing each set of lesson exercises, compare your answers with those

on the solution sheet that follows the exercises. If you have answered an exercise
incorrectly, check the reference cited after the answer on the solution sheet to
determine why your response was not the correct one.

MD0579 ii

Credit Awarded:

Upon successful completion of the examination for this subcourse, you will be

awarded 6 credit hours.

To receive credit hours, you must be officially enrolled and complete an

examination furnished by the Nonresident Instruction Branch at Fort Sam Houston,
Texas.

You can enroll by going to the web site http://atrrs.army.mil and enrolling under

"Self Development" (School Code 555).

A listing of correspondence courses and subcourses available through the

Nonresident Instruction Section is found in Chapter 4 of DA Pamphlet 350-59, Army
Correspondence Course Program Catalog. The DA PAM is available at the following
website: http://www.usapa.army.mil/pdffiles/p350-59.pdf.

MD0579 iii

LESSON ASSIGNMENT

LESSON 1

Anatomy and Physiology of the Genitourinary System

LESSON ASSIGNMENT

Paragraphs 1-1 through 1-9.

LESSON OBJECTIVES

After completing this lesson, you should be able to:

1-1.

Identify the structure, location, and function of

the

kidneys.

1-2.

Identify

the

structure, location, and function of

the

kidneys.

1-3.

Identify the structure, location, and function of

the

ureters.

1-4.

Identify the structure, location, and function of

the

bladder.

1-5.

Identify the structure, location, and function of

the

urethra.

1-6.

Identify

terminology, physiology, and important

characteristics of urine.

1-7.

Identify

internal

and external components and

functions of the male genitalia.

1-8.

Identify

characteristics, structures, and functions

of the female genital system.

SUGGESTION

After completing the assignment, complete the

exercises at the end of this lesson. These exercises

will help you to achieve the lesson objectives.

MD0579 1-1

LESSON 1

ANATOMY AND PHYSIOLOGY OF THE GENITOURINARY SYSTEM

1-1. INTRODUCTION

The term "genitourinary" actually refers to two different systems. Urinary refers

to the system responsible for removal of nitrogenous waste products of metabolism
from the bloodstream, disposal of concentrated wastes (urine), and also water
conservation. Genito refers to the genital organs and the reproductive system, which is
responsible for production of succeeding generations for perpetuation of the species.

1-2. URINARY

SYSTEM

The urinary system's primary function is to help keep the body in homeostasis

(internal environment of the body remains relatively the same, within limits) by
controlling the composition and volume of blood. The urinary system does this by
removing and restoring selected amounts of water and solutes. The urinary system is
made up of two kidneys, two ureters, one urinary bladder, and one urethra. Each
kidney, the primary organs of this system, excretes urine through a ureter. The urine is
stored in the urinary bladder and finally expelled from the body through the urethra.
See figures 1-1 and 1-2 for organs of the urinary system

NOTE:

Other systems also have a part in waste elimination from the body. These

systems are the respiratory, integumentary, and digestive systems

1-3. KIDNEYS

The two kidneys are reddish, bean-shaped organs. They are located on the

posterior wall of the abdominal cavity between the level of the twelfth thoracic vertebra
(T-12) and the third lumbar vertebra (L3). Think of these organs as being just above the
waist. The term for their location is retroperitoneal, which means that they are external
to the peritoneal lining of the abdominal cavity. These organs are about 11 to 12
centimeters long and 5 to 6 centimeters wide. Since the liver occupies a large space on
the right side of the abdominal cavity, the right kidney is slightly lower than the left
kidney. The kidneys are held in place by fat. See figure 1-3.

MD0579 1-2

Figure 1-1. Organs of the male urinary system.

MD0579 1-3

Figure 1-2. Urinary system organs.

MD0579 1-4

Figure 1-3. External view of the right kidney.

a. Functions of the Kidneys. The kidneys accomplish these functions:

(1) Filter metabolic wastes. The kidneys remove wastes from the blood in

the form of urine.

(2) Form urine. Urine is formed by the activities of the kidneys.

(3) Balance fluid and electrolytes. The kidneys are the organs that regulate

the composition and volume of blood.

(4) Balance acid base.

(5) Influence blood pressure. To aid in regulating blood pressure, the

kidneys secrete the enzyme renin.

MD0579 1-5

Kidney Tissue. The kidneys are composed of three types of tissue: capsule

tissue, cortex tissue, and medulla tissue. Capsule tissue is tough, white fibrous
connective tissue on the kidney surface. Cortex tissue covers the outer portion of the
kidney. Cortex tissue is firm and reddish-brown in color. Medulla tissue makes up the
masses of collecting tubes, which are the inner portion of the kidneys. The renal
pyramids and papillae are composed of medulla tissue. Cortex tissue extends between
the renal pyramids and the conical masses of tubes in the inner part of the kidneys.
Cortex tissue forms an outer layer on the kidneys and medulla forms inner kidney renal
columns. See figure 1-4.

Figure 1-4. Diagram of a cross section of the right kidney.

MD0579 1-6

Hilium. The hilium is a notch near the center of the rounded border of each

kidney. Blood vessels and the ureter enter each kidney at this point.

d.

Renal Pelvis. The part of the kidney that is the collecting point for urine

formed in the kidneys is called the renal pelvis. Peristalsis carries urine from the renal
pelvis to the ureter.

e.

Nephron. The nephron is the functional unit of the kidney. It is estimated

that each kidney has about a million nephrons. Each nephron consists of a renal
corpuscle and a tubular system. See figure 1-5.

NEPHRON = renal corpuscle + tubular system

Figure 1-5. A "typical" nephron.

MD0579 1-7

(1)

Renal corpuscle.

(a) Structure. The renal corpuscle has a hollow, double-walled sac

called the renal capsule (Bowman's capsule). Leading into the capsule is a very small
artery called the afferent arteriole. Within the capsule, this artery becomes a mass of
capillaries known as the glomerulus. An efferent arteriole drains blood away from the
capsule. The capsule and glomerulus together are known as the renal corpuscle.

(b) Function. An afferent arteriole supplies blood to the glomerulus.

An efferent arteriole drains blood from the glomerulus. The blood from the afferent
arteriole fills the glomerulus. Because of a pressure gradient, a large percentage of
fluid in this blood passes through the wall of the glomerular capillary. The fluid then
passes through the inner wall of the capsule. This brings the fluid into the hollow space
between the inner and outer walls of the renal capsule.

AFFERENT = carry to

EFFERENT = carry away from

(2)

Renal tubule.

(a) Structure. Each renal capsule is drained by a renal tubule. This

part of the tubular system runs a long distance in a coiled formation and is called the
proximal convoluted tubule. A long loop, the renal loop of Henle extends down into the
medulla with two straight parts and a sharp bend at the bottom. As the tube returns to
the cortex layer, it once again becomes coiled and is known here as the distal
convoluted tubule. The distal convoluted tubule is the end of the nephron unit.

(b) Reabsorption. The renal tubule reabsorbs the fluid or filtrate

passing through the tubular system, of the nephron. As fluid or filtrate passes through
the renal tubule, the majority of the water, glucose, and other valuable substances are
removed from the fluid, reabsorbed in the tubule, and returned to the cardiovascular
system. Essential electrolytes such as sodium, chloride, and bicarbonate are
reabsorbed in the tubules. The hormone aldosterone controls the reabsorption of
sodium salts. Aldosterone is a hormone produced in the adrenal gland. Water and
nonelectrolytes such as glucose, amino acids, and nutrients are also absorbed by renal
tubes.

Tubular reabsorption removes substances from the filtrate into the blood and also adds
materials to the fluid from the blood. Substances secreted by renal tubules include
potassium ions, hydrogen ions, ammonia, creatinine, and the drugs penicillin and
aminohippuric acid. There are two main effects from tubular secretions. The
substances in the secretions help rid the body of certain materials and also help control
the blood pH.

MD0579 1-8

(3)

Summary.

(a) The major work of the urinary system is done by the nephrons. The

other parts of the urinary system are mainly passageways and storage areas. Each
nephron is made up of a renal corpuscle and a tubular system. Three important
functions are carried out by nephrons.

1 Nephrons control blood concentration and volume by removing

selected amounts of water and solutes.

2 Nephrons help regulate blood pH.

3 Nephrons remove toxic wastes from the blood.

(b) As the nephrons go about these activities, they remove many

materials from the blood, return the ones that the body requires, and eliminate the
remainder. The eliminated materials are collectively called urine. The entire volume of
blood in the body is filtered by the kidneys about 60 times a day.

f.

Collecting Tubules. The distal convoluted tubules of several nephrons

empty into a collecting tubule. That is, several tubules join larger tubules of a renal
pyramid to form one tubule that opens at a renal papilla and drains into a calyx in the
renal pelvis. The final reabsorption of electrolytes, water, and glucose takes place in
these collecting tubules. Also, the final secretion of electrolytes and nonelectrolytes
takes place here.

1-4. URETERS

A ureter is a tubular structure that is continuous with the renal pelvis. The

ureters, one for each kidney, are musculomembranous in structure, 10 to 12 inches
long, and form the upper part of the renal pelvis of the kidney. The ureters convey urine
from the kidneys to the bladder by the process of peristalsis. Urine moves along the
ureters drop by drop, pushed by the wave-like muscular contractions of peristalsis of the
tubular wall. From the renal pelvis, the urine drains into the ureters, entering the urinary
bladder at its base. See figure 1-6.

MD0579 1-9

Figure 1-6. Urinary bladder and female urethra.

MD0579 1-10

1-5. URINARY

BLADDER

The urinary bladder is a musculomembranous sac located in the lower portion of

the abdominal cavity behind the symphysis pubis. The organ is highly specialized to
store urine until the urine is eliminated from the body.

a.

Trigone. The base of the urinary bladder is known as the trigone because of

its triangular shape. The trigone is fairly solid and nonstretchable. See figure 1-6.

b.

Stretchable Wall. The rest of the wall of the urinary bladder is very

stretchable and forms a spherical sac when filled.

c.

Transitional Epithelial Lining. The mucosal lining of the urinary bladder is

made up of a unique epithelium called the transitional epithelium.

(1)

Voiding reflex. The transitional epithelium has the capacity to stretch to

a certain degree. At the limit of its stretchability, it causes a message to be sent to the
spinal cord about the fullness of the urinary bladder. This initiates the voiding reflex,
which causes the urine to pass out of the body.

(2)

Increments of stretching and reorganization. Often, however, it is not

convenient to void (empty the bladder). Thus, after a short period of time, the
transitional epithelium can reorganize itself and undergo another increment of
stretching. Soon, however, the fullness message is somewhat more urgent. There can
be several increments of stretching until the limit of the urinary bladder has been
reached. At that limit, the urine must be voided.

1-6. URETHRA

The urethra is a tube that conducts urine from the urinary bladder to the outside

of the body. This structure begins at the anterior base of the urinary bladder.

a. Male-Female Differences. The female urethra is short and opens directly to
the outside. The male urethra, however, is much longer and has two curvatures. The
male urethra is divided into three sections: prostatic, membranous, and penile. The
prostatic portion enters the prostate gland. The membranous portion enters the
peritoneum and the penile portion forms in the shaft of the penis.

b. Urethral Sphincters. The urethral sphincters are two muscular structures
that prevent urine from leaving the urinary bladder. Each urethral sphincter is a circular
mass of muscle tissue. Relaxation of the sphincters allows urine to be forced through
them.

NOTE:

Remember the difference between the ureter and the urethra. The ureter is a

tube draining urine from the kidneys to the urinary bladder. The urethra is a

tube draining urine from the urinary bladder to the outside.

MD0579 1-11

1-7. URINE

Urine is a by-product of the kidney's activity. Volume, pH, and solute

concentration vary with the needs of the body's internal environment in a healthy
person. The characteristics of urine may change greatly when a person is ill. It is
possible to find out a great deal about the state of a body by analyzing the volume,
physical properties, and chemical properties of urine.

a.

Physical Characteristics. Normal urine is yellow or amber colored and

transparent. The color, caused by pigments from the metabolism of bile, can change because
of medication or diet. A person eats beets and his urine may be a reddish color.
An individual takes large amounts of vitamin C and his urine may be deep yellow for a
time. The odor of urine varies. Stale urine develops an ammonia odor (think of a
baby's diaper), but the urine that is expelled after the digestion of asparagus will have a
completely different, but characteristic, odor.

b.

Composition. About 95 percent of the total volume of urine is water. The

other 5 percent is made up of solutes that come from cellular metabolism and outside
sources such as drugs. Included in the 5 percent are nitrogenous waste products,
electrolytes, toxins, and urea. Urea, an end product formed in the liver from protein
metabolism, is the chief nitrogenous waste product in the non-water portion of urine.

NOTE:

One of the screening tests for renal function is the blood urea nitrogen (BUN)

test. It is the most commonly ordered test. It measures blood levels of

nitrogen in urea. This test is not sensitive to mild degrees of renal

dysfunction, but it is a good clinical indication of significant renal dysfunction.

Specific Gravity. This is the ratio of the weight of a volume of a substance to

the weight of an equal volume of distilled water. The specific gravity of water is 1.000.
The specific gravity of urine depends on the amount of solid materials in the urine. The
specific gravity of normal urine ranges from 1.010 to 1.020. The greater the
concentration of solutes in the urine, the higher its specific gravity.

d.

Amount Voided. A normal adult eliminates about 1500 cubic centimeters of

urine daily. The amount of urine voided depends on a number of factors: blood
pressure, blood concentration, diet, temperature, diuretics, mental state, and general
health.

e.

Acidity/Alkalinity of Urine. Normal urine is slightly acid, but the acidity and

alkalinity of urine varies greatly with an individual's diet. A high-protein diet increases
the acidity of urine while a diet consisting of mostly vegetables increases the alkalinity of
urine. Other factors influencing urinary pH include high altitude, fasting, and exercise.

MD0579 1-12

1-8.

MALE GENITAL SYSTEM

a. External Genitalia. The penis and the scrotum are the external parts of the
male genital system. See figure 1-7.

Figure 1-7. Male genital system.

(1)

Penis. The penis is the male organ of copulation and urination. The

shaft of the penis is made up of three cylindrical masses of tissue bound together by
fibrous tissue. The two back and side tissue masses are called the corpora cavernosa
penis. The smaller third tissue mass is the corpus spongiosum penis located toward the
middle of the shaft and containing spongy urethra. These three tissue masses are
erectile (capable of erection) and contain blood sinuses (channels). When sexually
stimulated, the arteries of the penis dilate. Large quantities of blood enter the blood
sinuses. Expansion of these spaces compresses the veins draining the penis, causing
most entering blood to be retained. An erection is caused by these vascular changes,
the erection being a parasympathetic reflex. When the arteries constrict and the
pressure on the veins is relieved, the penis returns to its flaccid (soft, limp) state. See
figure 1-8.

MD0579 1-13

Figure 1-8. Internal structure of the penis.

(2)

Glans. The terminal enlarged end of the penis is called the glans. (The

word glans means shaped like an acorn.) This portion of the penis is formed by that
part of the spongy body that extends beyond the cavernous bodies of the penis shaft.
The glans is highly innervated (tactile).

b.

Internal Genitalia. Internal genitalia include the testes, epididymis, vas

deferens, ductus deferens, seminal vesicles, ejaculatory duct, prostrate gland,
bulbourethral (Cowper's) gland, and the urethra.

MD0579 1-14

(1)

Testes. The testes are the primary organs of reproduction in the male.

The male testes correspond to the female ovaries. Located in the scrotum, the testes
are oval structures enclosed in a fibrous capsule. A dense layer of white fibrous tissue
called the tunica albuginea covers the testes. This tissue layer extends inward and
divides each testis into a series of internal compartments called lobules. Each of the
200 to 300 lobules contains one to three tightly coiled tubules called the seminiferous
tubules. These tubules produce sperm by a process called spermatogenesis.
Interstitial cells within the testes produce testosterone, the hormone that is essential for
the development of the male secondary sex characteristics. Growth of hair on the face
and body, deepening of the voice, and an increase in skeletal muscle mass do not
occur in a male whose body does not produce testosterone.

(2)

Epididymis. At the upper and posterior part of each testes is located an

epididymis, an elongated triangular tube which is 16 to 20 feet in length. Each of these
two tubes is tightly coiled. Sperm mature in the epididymis tubes. These tubes link the
testes proper with the ductus deferens. Sperm are stored in the epididymis tubes until
they are ejaculated and enter the ductus (vas) deferens.

(3)

Ductus (vas) deferens. At the tail of the epididymis, the epididymis

becomes less coiled, its diameter increases, and the tube becomes known as the
ductus (vas) deferens. Vas deferens are muscular tubes about 48 centimeters (18
inches) long. Two vas deferens, one from each epididymis tube, lead up through the
inguinal canal into the pelvic cavity, cross to the inferior surface of the urinary bladder,
and unite with the ducts of the seminal vesicles to form the ejaculatory ducts.

(4)

Seminal vesicles. The seminal vesicles are two glandular pouches

located behind and below the urinary bladder. These tubular structures secrete a
substance that activates the spermatozoa in the semen. The secretions contain
fructose and prostaglandins. Fructose energizes the sperm, and prostaglandins assists
ejaculation and stimulates uterine contractions. Thus, both fructose and prostaglandins
help sperm move to the uterine tubes where fertilization occurs. Additionally, seminal
fluid is slightly alkaline and the seminal vesicles' secretions help protect sperm against
the acid secretion of the vagina. Secretion of the seminal vesicles makes up 60 percent
of the ejaculate. See figure 1-9.

(5)

Ejaculatory duct. Each ductus deferens and its corresponding seminal

vesicle coverage to form a short tube called the ejaculatory duct. The ejaculatory duct
opens into the urethra within the prostate gland. The ejaculatory duct carries both
sperm and seminal vesicle fluid.

MD0579 1-15

Figure 1-9. Seminal vesicles and other male organs of the genitourinary system.

(6)

Prostate gland. This gland is a single doughnut-shaped gland about the

size of a chestnut. The gland lies directly below the urinary bladder and surrounds the
prostatic part of the urethra. The prostate gland secretes a highly alkaline fluid that
protects sperm acidity in the urethra and vagina. Secretion from the prostate gland is
added to the sperm and seminal vesicle fluid. From 13 to 33 percent of the volume of
semen seminal vesicle fluid is prostate gland secretion. Prostate gland secretion also
contributes to sperm motility.

(7)

Bulbourethral (Cowper's) glands. These are two small glands, about the

size of peas, located just below the prostate on either side of the urethra. These glands
secrete a mucous-like lubricating fluid into the membranous urethra. The glands also
secrete a substance that neutralizes urine. Ducts of these glands open into the spongy
urethra.

(8)

Urethra. The urethra is a passageway for sperm and urine. The

urethra, measuring about 20 centimeters (8 inches) in length, passes through the
prostate gland, the urogenital diaphragm, and the penis.

MD0579 1-16

1-9.

FEMAL GENITAL SYSTEM

External Genitalia. The vulva and its parts make up the external genitalia.

The word vulva is a term that has been designated to stand for the external genitalia of
the female. See figure 1-10.

(1)

Mons pubis. The elevated, fatty tissue covered with coarse pubic hair

and which lies over the symphysis pubis is the mons pubis. Pubic hair appears at
puberty. The function of the mons pubis is to protect the pelvic bone.

(2)

Labia majora. The labia majora are large longitudinal folds of skin and

fatty tissue extending back from the mons pubis to the anus. The outer surfaces are
covered with hair. The inner surfaces are smooth and moist. The corresponding
structure in the male is the scrotum. The function is to protect the entrance to the
vagina.

(3)

Labia minora. The labia minora is composed of two folds of skin lying

within the labia majora and enclosing the vestibule. In front, each labium minus
(minus is the singular form of minora) divides into two folds. The fold above the clitoris
is called the prepuce of the clitoris. The fold below is the frenulum. No pubic hair is on
these structures:

Figure 1-10. Female genital system.

MD0579 1-17

(4)

Clitoris. The clitoris is a small projection of sensitive erectile tissue,

which corresponds to the male penis. The female urethra, however, does not pass
through the clitoris. As in the male penis, the clitoris is covered by prepuce.

(5)

Urinary meatus. The urinary meatus is located between the clitoris and

the vagina.

(6)

Vaginal orifice. This is the opening to the vagina from the outside.

(7)

Bartholin's gland. These are bean-shaped glands located on each side

of the vaginal orifice. They provide lubrication of the vagina.

(8)

Perineum. The perineum is the area between the vaginal orifice

(opening) and the rectum. The perineum is sometimes referred to as the pelvic floor.

b. Internal Genitalia. See figure 1-10.

(1)

Uterus or "womb." The uterus is a hollow, muscular, pear-shaped

organ. It is located in the pelvic cavity between the urinary bladder and the rectum.
During a woman's child-bearing years, the uterus is about 7.5 centimeters long, 5
centimeters wide, and 2.5 centimeters thick. The three anatomical divisions of the
uterus are the fundus, the body, and the cervix. The fundus is the upper, convex part of
the uterus. This part of the uterus is located just above the entrance to the fallopian
tubes. The body is the central part of the uterus and the cervix is the lower, neck-like
part of the uterus.

(a) Walls of the uterus. The walls of the uterus are made up of three

layers: the endometrium, the myometrium, and the parietal peritoneum. The
endometrium, the inner layer, attaches itself to the myometrium layer and lines the
uterus. This layer is sloughed off during menstruation or post delivery. The middle
layer, which is composed of smooth muscle, is the myometrium. This layer is made up
of longitudinal, circular, and spiral muscular fiber that interlaces. This middle layer of
wall is thickest in the fundus and thinnest in the cervix. During childbirth, this muscle
layer is capable of the very powerful contractions necessary for a normal birth. The
third layer, the parietal peritoneum, is the outer layer and is a serous membrane (a
membrane that lines body cavities but does not open to the exterior). This layer of wall
is incomplete and covers only part of the uterine body and none of the uterine cervix.

(b) Functions of the uterus. The uterus holds the fertilized egg during

its growth and development during pregnancy. The fetus grows in the uterus. During
the birth process, the uterus produces powerful contractions to expel the mature infant.
And, finally, during a female's menstrual phase, fluid is discharged from the uterine
cavity. Three functions of the uterus are, therefore, pregnancy, labor, and menstruation.

MD0579 1-18

(2)

Uterine tubes, fallopian tubes, or oviducts.

(a) Description/information. These two tubes, known by all three

names listed above, extend from the uterus to the ovaries. The ova move from the
ovaries along these tubes to the uterus. The tubes are about 10 centimeters (4 inches)
long and are positioned between the folds of the broad ligaments of the uterus. The
tubes are attached to the uterus at one end but not attached to the ovaries at the other
end. At the ovary end, the tubes are open and funnel-shaped and close to the ovary.
The funnel-shaped end of the tubes are called the infundibulum. At these ends are
fringe or finger-like processes called fimbriae. The outer edge of the infundibulum are
continuous with the peritoneum (the largest serous membrane of the body).

(b) Description/information. These two tubes, known by all three

(3)

Ovaries.

(a) Description/information. The ovaries are two almond-shaped

glands located on either side of the uterus below and behind the uterine tubes.
Detached from the uterine tubes, the ovaries are held in position by a series of
ligaments. During the second phase of the menstrual cycle, one of the 20 to 25 primary
follicles that has developed in an ovary, matures into a Graafian follicle, a follicle ready
for ovulation. During the maturation process, this follicle increases its estrogen
production. The rupture of the Graafian follicle, with the release of the ovum, is the
beginning of ovulation.

(b) Functions. A major function of the ovaries is to produce ova

(female reproductive cells capable of developing, after fertilization, into new individuals).
Other functions include discharge of ova (ovulation) and secretion of the female sex
hormones, which are progesterone, estrogen, and relaxin. The ovaries in the female
correspond to the testes in the male reproductive system.

MD0579 1-19

(4)

Vagina.

(a) Description/information. The vagina is a muscular, tubular organ

lined with mucous membrane. This organ is about 10 centimeters (4 inches) long and
extends from the hymen to the cervix. The vagina extends upward and backward
between the rectum and the bladder and is attached to the uterus.

(b) Structure. The lining of the vagina is made up of smooth muscle

that is longitudinally and circularly arranged in many folds called rugae. The folds of the
lining permit the organ to expand when necessary. The hymen is the fold of mucous
membrane at the orifice (opening) of the vagina.

receives seminal fluid from the male, and serves as the lower part of the birth canal.

Continue with Exercise

MD0579 1-20

EXERCISES, LESSON 1

INSTRUCTIONS. Answer the following exercises by writing the answer in the space
provided.

After you have completed all of these exercises, turn to "Solutions to Exercises" at the
end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1. What is the primary function of the urinary system?

______________________________________________________________

______________________________________________________________.

2. List the major parts of the urinary system.

a.

__________________________________________________________.

3. List three functions of the kidneys.

a.

__________________________________________________________.

4. The notch near the center of the rounded border of each kidney is called the:

____________________________________________________________.

5. The collecting point for urine in the kidney is called the:

____________________________________________________________.

MD0579 1-21

6. List the three important functions carried out by the nephron units in the kidneys.

a.

__________________________________________________________.

7. Where is the urinary bladder located?

_____________________________________________________________.

8. Name the reflex that causes urine to pass out of the body.

_____________________________________________________________.

9. What is the difference between the female urethra and the male urethra?

_____________________________________________________________.

_____________________________________________________________.

10. The two muscular structures which prevent urine from leaving the urinary bladder

are the __________________________________________________________.

11. Approximately 95 percent of the total volume of urine is __________________.

12. The blood urea nitrogen (BUN) test is a screening test for

_____________________________________________________________.

13. SSG Gilmore is following a high-protein diet. What effect will this diet have on the

acidity of his urine?

_____________________________________________________________.

MD0579 1-22

14. Name the terminal enlarged end of the penis.

_____________________________________________________________.

15. The two glandular pouches located behind and below the urinary bladder are the

_____________________________________________________________.

16. Two pea-shaped glands located just below the prostate on either side of the

urethra in the male secrete a substance that neutralizes urine. These glands are

the _____________________________________________________________.

17. What is the hollow, muscular, pear-shaped organ located in the pelvic cavity

between the urinary bladder and the rectum of the female?

_____________________________________________________________.

18. List the three functions of the uterus.

a.

__________________________________________________________.

19. The

_____________________________________________________________

tubes extend from the uterus to the ovaries.

20. What hormones do the ovaries secrete?

a.

__________________________________________________________.

MD0579 1-23

21. List the three functions of the vagina.

a.

__________________________________________________________.

Check Your Answers on Next Page

MD0579 1-24

SOLUTIONS TO EXERCISES, LESSON 1

1. The primary function of the urinary system is to help keep the body in

homeostasis by controlling the composition and volume of blood. (para 1-2)

2. Two kidneys.
Two

ureters.

One urinary bladder.

One urethra. (para 1-2)

3. You are correct if you listed any three of the following:

Filtration of metabolic wastes.

Urine

formation.

Fluid and electrolyte balance.

Acid

base

balance.

Influence blood pressure. (para 1-3a)

4. Hilium. (para 1-3c)

5. Renal pelvis. (para 1-3d)

6. Control blood concentration and volume by removing selected amounts of

water and solutes.

Help regulate blood pH.

Remove toxic wastes from the blood. (para 1-3e(3)(a)1, 2, 3)

7. The urinary bladder is located in the lower portion of the abdominal cavity behind

the symphysis pubis. (para 1-5)

8. The voiding reflex. (para 1-5c(1))

9. The female urethra is short and opens directly to the outside. The male urethra

is much longer and has two curvatures. (para 1-6a)

10. Urethral

sphincters. (para 1-6b)

11. Water. (para 1-7b)

12. Renal function. (para 1-7b, NOTE)

13. There will be increased acidity of his urine. (para 1-7e)

MD0579 1-25

14. The glans. (para 1-8a(2))

15. Seminal vesicles. (para 1-8b(4))

16. Bulbourethral

or Cowper's glands. (para 1-8b(7))

17. Uterus. (para 1-9b(1))

18. Holds the fertilized egg during its growth and development during pregnancy.

Produces powerful contractions to expel the mature infant during labor.

Fluid is discharged from the uterine cavity during a female's menstruation.

(para

1-9b(1)(b))

19. Uterine , fallopian , or oviducts. (para 1-9b(2)(a))

20. Progesterone.
Estrogen.

Relaxin. (para 1-9b(3)(b))

21. Passageway for menstrual flow.

Receives seminal fluid from the male.

Serves as lower part of the birth canal. (para 1-9b(4)(c))

End of Lesson 1

MD0579 1-26

LESSON ASSIGNMENT

LESSON 2

Physical Assessment of the Genitourinary System

LESSON ASSIGNMENT

Paragraphs 2-1 through 2-4.

LESSON OBJECTIVES

After completing this lesson, you should be able to:

2-1.

Identify historical data pertinent to the physical

genitourinary

assessment of the genitourinary

system.

2-2.

Identify the procedures for performing a physical

assessment of the male and female

genitourinary

systems.

SUGGESTION

After completing the assignment, complete the

exercises at the end of this lesson. These exercises

will help you to achieve the lesson objectives.

MD0579 2-1

LESSON 2

PHYSICAL ASSESSMENT OF THE GENITOURINARY SYSTEM

2-1. INTRODUCTION

Genitourinary (GU) problems are fairly common and tend to occur in all age

groups. If neglected, these problems can lead to severe pain, morbidity, or even death.
This lesson will teach you ways to approach and assess the GU problem or complaint in
a very systematic way and to complete a patient history relevant to the genitourinary
assessment.

2-2. PATIENT'S

GENITOURINARY HISTORY

The purpose of taking a patient's history is to learn about the patient so that his

present problem can be diagnosed and treated. Generally, taking the patient's history
proceeds by obtaining information from him in these areas--the chief complaint, the
present problem, past medical history, and family history. Some specific questions can
be asked of the patient to obtain necessary information about him.

a.

Chief Complaint. Ask the question, "What problem or symptoms brought

you here?" Then ask, "How long has this problem been present?" or "When did these
symptoms begin?"

b.

Present Problem or Illness. Ask for the signs and symptoms of the

problem. When did the patient last feel well? What things make the problem worse?
What makes the patient feel better? How does the problem affect the patient's lifestyle
(marriage, leisure activities, ability to perform tasks, ability to cope with stress)? How
has the problem progressed up to the present point (steadily worsening or periods of
being better followed by periods of worsening)?

c.

Information Specific to the Genitourinary System. The genitourinary

history of a patient should include certain pertinent information as follows:

(1)

Urinary system.

(a)

Trauma.

(b) Infections or diseases.

(d)

Physical

abnormalities.

MD0579 2-2

(e) Venereal history (also affects the reproductive system).

(f)

Dysuria (difficulty or pain in urination).

(2)

Reproductive system. Obtain information about the following:

(a) Menstrual history of a female should include information about her

last menstrual period (LMP) and post-menstrual pain (PMP). Ask the number of times
she has been pregnant (gravida), the number of pregnancies carried past 20 weeks
(para), and the number of abortions (AB).

(b)

Fertility

(asked

of both men and women).

asked in very extensive histories. DO NOT question a patient about these areas in a
routine physical examination.

2-3.

PROCEDURES FOR PHYSICAL ASSESSMENT OF THE GENITOURINARY

SYSTEM

The physical assessments of the genitourinary system for the male and female

have similarities and differences. Procedures for assessment of the rectal areas are the
same for each gender.

a. Male Genitalia Inspection. Examine as follows:

(1) Examine the foreskin by retraction. Check for phimosis (constriction of

the preputial orifice so that the prepuce cannot be retracted over the glans).

(2) Look for lesions, chancres (primarily sores associated with syphilis).

(3) Examine the glans for ulcers, scars, and inflammation.

(4) Check the location of the urethra. A congenital defect that appears in

the male is hypospadias in which the urethra opens on the undersurface of the penis.
Epispadias is a congenital defect that can occur in males and females. In the male, the
urethra opens on the dorsal side of the penis; in the female, there is a fissure in the
upper wall of the urethra.

(5) Check for discharge from the meatus.

(6) Examine the skin around the base of the penis for inflammation, nits, or

lice.

(7) Check the scrotum for swelling and inflammation.

MD0579 2-3

Male Genitalia Palpation. Examine as follows:

(1)

Testes. Check the testes for:

(a) Masses that are tender.

(b) Tumors that won't transluminate.

(d) Varicocele (swelling that feels like a bag of worms in the scrotum).

(2)

Epididymis. Check for:

(a) Soft mass of tissue posterior to the testicle.

(b) Epididymitis (inflammation of the epididymis).

(3)

Direct inguinal hernia. Check for a bulge. A large bulge is rare. A minor

bulge may only be felt with the finger in the inguinal canal.

(4)

Indirect inguinal hernia. Examine as follows:

(a) Protrusion of abdominal contents through the inguinal canal and

often into the scrotum.

(b) Indirect hernia can resolve on recumbent position.

Female Genitalia Inspection. Follow this procedure:

(1) Ensure proper equipment (speculum, lubricant, gloves) is set up.

(2) Have the patient void (to avoid discomfort during the examination).

(3) Be sure a chaperon is available.

(4) Check the external genitalia using a gloved hand.

(5) Check for inflammation, discharge, swelling, or ulceration of the

following:

(a) External genitalia (with a gloved hand): labia minora, clitoris,

urethral opening, and vaginal opening.

(b) Internal genitalia (examine with a speculum): vagina and cervix.

MD0579 2-4

(6) Check to see if laboratory specimens for a pap smear or other

scrapes/swab tests are needed.

d.

Male and Female Rectal Inspection. Examine as follows:

(1) Palpate the rectum.

(2) Check for lesions on the rectal walls.

(3) Check a stool for blood.

2-4. CLOSING

Since ancient times, man has recognized the seriousness of genito-urinary

problems. Today, with all of our modern technology, we can identify and treat many of
these conditions that have resulted in death in the past. The transplanting of kidneys is
only one of the many modalities available to us. But a complete and thorough history
and physical examination is still one of our most valuable tools. Such an examination
can be your faithful companion if you master it.

Continue with Exercises

MD0579 2-5

EXERCISES, LESSON 2

INSTRUCTIONS. Answer the following exercises by writing the answer in the space
provided.

After you have completed all of these exercises, turn to "Solutions to Exercises" at the
end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1.

The genitourinary history of a patient should include trauma, infections or

diseases, incontinence, physicalabnormalities, Dysuria (difficulty or pain in

urination) and ___________________________________________________.

Menstrual history of a female should include information about her last menstrual

period (LMP) and post-menstrual pain (PMP). A female patient should be asked

how many pregnancies she has carried past _________________ weeks.

What questions about reproductive system should not be asked to a patient

during a routine physical examination?

_____________________________________________________________.

4.

Examine a male's glans for inflammation, ulcers, and ___________________.

Examine female external and internal genitalia for discharge, ulcerations,

inflammation, and _______________________________________________.

Equipment you should gather before inspecting the female genitalia includes

lubricant, speculum, and ___________________________________________.

MD0579 2-6

Female external genitalia examined with a gloved hand include the clitoris,

labia minora, vaginal opening, and ___________________________________.

List the three parts of the male and female rectal examination.

__________________________________________________________.

Checking for spermatocele and varicocele are done during

_____________________________________________________________.

10.

A bulge anterior to the scrotum may indicate the patient has a

_____________________________________________________________

Check Your Answers on Next Page

MD0579 2-7

SOLUTIONS TO EXERCISES, LESSON 2

1.

Venereal history (also affects the reproductive system).

(para 2-2c(1)(a) - (e))

20. (para 2-2c(2)(a))

Libido and potency. (para 2-2c(2)(c))

Scars. (para 2-3a(3))

Swelling. (para 2-3c(5))

Gloves. (para 2-3c(1))

Urethral opening. (para 2-3c(5)(a))

Palpate the rectum.

Check for lesions on the rectal walls.

Check a stool for blood. (para 2-3d(1) - (3))

Male genitalia palpation. (para 2-3b(1)(c), (d))

10.

Direct inguinal hernia. (para 2-3b(3)(b))

End of Lesson 2

MD0579 2-8

LESSON ASSIGNMENT

LESSON 3

Urinary System Diseases/Disorders

LESSON ASSIGNMENT

Paragraphs 3-1 through 3-37.

LESSON OBJECTIVES

After completing this lesson, you should be able to:

3-1.

Identify the etiology, signs, symptoms, and

treatment for urinary tract infections.

3-2.

Identify the etiology, signs, symptoms, and

treatments for these kidney diseases/disorder.

Acute

glomerulonephritis.

Pyelonephritis.

Hydronephrosis.

Acute renal failure.

Chronic renal failure.

Renal

tumors.

Polycystic

kidney.

Renal

calculi.

3-3.

Identify the etiology, signs, symptoms, and

treatments

for

abnormalities and obstructions of

the

ureters.

3-4.

Identify the etiology, signs, symptoms, and

treatments

for

these bladder disorders:

Cystitis.

Tumors.

3-5.

Identify these disorders of the urethra:

Congenital

defects.

Urethritis.

"Straddle

Injuries."

Trauma.

MD0579 3-1

3-6.

Identify the etiology, signs, symptoms, and

treatments

for

injuries to these organs of the

genitourinary

system:

Kidney

injuries.

Bladder

injuries.

Urethral

injuries.

3-7.

Identify adverse reactions and contraindications

that apply to a specific drug treatment for urinary

system diseases and disorders.

SUGGESTION

After completing the assignment, complete the

exercises at the end of this lesson. These exercises

will help you to achieve the lesson objectives.

MD0579 3-2

LESSON 3

URINARY SYSTEM DISEASES/DISORDERS

Section I. URINARY TRACT INFECTIONS

3-1. INTRODUCTION

More than 8 million Americans are affected by urinary system related health

problems, which means you may deal with many patients with urinary system
complaints. The urinary system plays a major part in the fluid and electrolyte balance of
the body and with the respiratory system is important in maintaining the blood pH. It is
understandable, therefore, that a problem with the urinary system can have serious
health consequences.

3-2.

ETIOLOGY OF URINARY TRACT INFECTIONS

Infecting Microorganisms. The cause of urinary tract infections (UTI) can

be traced to the presence of infectious microorganisms located anywhere between the
kidneys and the urethral opening. The common pathogens are the gram-negative
bacilli, often found in the colon, especially E. coli, klebsiella, and proteus.
Microorganisms acquire access to the kidneys by ascension from the lower urinary tract
beginning at the urethra. Bacterial infections of the lower urinary tract occur about 10
times more frequently in females than in males. A common cause of urinary tract
infection in females is an improper wiping technique.

b.

Predisposing Factors. Factors which predispose an individual to UTI

include sex, stasis of the urine, instrumentation, and neurogenic bladder.

(1)

Sex of the individual. Urinary tract infections are common in females of all ages

because the female urethra is short. Additionally, large numbers of pyogenic bacteria
(pus-producing bacteria) inhabit the vaginal vestibule. Urinary tract infections are rare
among males less than 50 years old because the male urethra is enclosed in the penis.
Ascending UTI infections frequently occur after intercourse.

(2)

Urinary stasis. Urinary stasis is the stoppage of the flow or discharge of

urine. This condition may be caused by stones, stricture (an abnormal narrowing of a
tubular structure), prostatic enlargement, tumor, or developmental abnormalities.
Urinary stasis may occur at any level of the urinary tract. The statis of urine from any
cause predisposes toward UTI. About 95 percent of people with catheters for three
days develop urinary tract infections.

(3)

Instrumentation. Instrumentation used (such as catheters), diagnostic

studies, and therapeutic procedures (such as bladder irrigations) are also causes of
urinary tract infections.

MD0579 3-3

(4)

Neurogenic bladder. Neurogenic bladder is the term used for any

disturbance of the bladder function that is caused by impairment of the nerve supply.
Such dysfunction can occur by prolonged urinary stasis in the bladder but is more
frequently caused by the use of catheters.

3-3.

SIGNS AND SYMPTOMS OF URINARY TRACT INFECTIONS

Pain, a primary symptom associated with urinary tract infection, involves the

kidneys, the ureter, and the bladder. Kidney pain will be manifested as a dull ache in
the flanks extending along the rib margin toward the umbilicus. (The flank is the side of
the body between the ribs and the pelvis.) In the ureter, pain radiates from the
costovertebral angle down the course of the ureter to the scrotum or vulva to the inner
thighs. During urination, the individual experiences bladder pain that radiates to the
distal urethra.

3-4.

LABORATORY PROCEDURES FOR URINARY TRACT INFECTIONS

Common laboratory procedures for urinary tract infection include the following:

routine analysis, culture sensitivity, blood tests, cystoscopic examination, and X-ray
procedures.

a. Routine Analysis. Routine analysis is done to check for abnormalities. A
routine analysis includes a check of the following:

(1) Specific gravity for testing the kidney's ability to concentrate urine.

(2) pH-balance to reflect the metabolic status.

(3) Presence of white blood cells, red blood cells, crystals, and casts (a

menstruating female will normally have red blood cells present).

(4) Glucose that is indicative of diabetes. Many drugs give false positive

tests for glucosuria. Examples of such drugs include Kelflex

, large doses of ascorbic

acid, penicillin, Benemid R

, tetracycline, and thiazides.

(5) Odor (a sweet smell) with a presence of acetone is associated with

diabetes mellitus, while an unpleasant smell is associated with decomposition or
ingestion of certain drugs or foods.

(6) Color and transparency. Pale urine indicates diabetes insipidus. If the

urine is milky, there may be fat globules or pus corpuscles present. Reddish urine may
indicate the presence of blood pigments, drugs, or food pigments. Greenish urine is
indicative of bile pigment, which is associated with jaundice. Brown-black urine may
indicate poisoning or hemorrhage.

MD0579 3-4

Specimens. Culture and sensitivity (clean catch) specimens are taken to

determine specific agents in infectious diseases of kidneys, ureters, and bladder. Good
cleaning techniques are essential, especially in women. In such cases, void and collect
midstream urine in a sterile cup. The patient can be catheterized (in and out
catheterization), but this is the last resort because of increased incidence of introducing UTIs
with catheterization. Specimens must be sent to the laboratory as soon as possible and
refrigerated, if needed.

c.

Additional Procedures.

(1)

Blood urea nitrogen (BUN). This is a blood test to help determine

whether the kidneys are clearing the body of waste properly. The body's blood
chemistry changes if the nephrons of the kidneys are not removing the body's waste
products efficiently. One change in blood chemistry is a rise in the blood urea nitrogen
level.

(2)

Cystoscopic examination. The cystoscopic examination is a direct

method of bladder study and visualization by cystoscopy using a tubular lighted
telescopic lens that is passed into the bladder via the urethra. It is used to detect
tumors, obtain biopsies, remove calculi (kidney stones), treat lesions, and inspect
tissue.

(3)

X-ray procedures. X-ray procedures includes the kidney, the ureter, and

the bladder (KUB) or flat plate of the abdomen. It shows the position, size, and shape
of the kidneys and renal calculi.

Section II. KIDNEY DISEASES AND DISORDERS

3-5. GENERAL

INFORMATION

Kidney disorders may be acute or chronic. Acute conditions usually arise

suddenly, most frequently as the result of an infection with inflammation of the
nephrons. Acute kidney disorders commonly run a course of a few weeks and are
followed by complete recovery. Chronic kidney conditions develop slowly. These are
often progressive, resulting in the gradual loss of kidney function.

MD0579 3-5

3-6. ACUTE

GLOMERULONEPHRITIS

Glomerulonephritis, a form of nephritis (inflammation of the kidneys) in which the

lesions involve primarily the glomeruli, is the most common kidney disease. In this
disease, antibodies formed in response to streptococci attach themselves to the
glomerular membrane and injure this membrane. (Glomeruli are the small, coiled mass
of blood capillaries within Bowman's capsule of the kidney.) These damaged glomeruli
allow protein, especially albumin, to filter into Bowman's capsule and, ultimately, to
appear in the urine (albuminuria). The damaged glomeruli also allow red blood cells to
filter into the urine (hematuria). The patient usually recovers without permanent kidney
damage. Sometimes, however, particularly in adult patients, the disease becomes
chronic with a gradual decrease in the number of functioning nephrons. This condition
leads to chronic renal failure.

a. Etiology of Acute Glomerulonephritis. The exact cause of this infection is
unknown. What is known is that a glomerulonephritis infection frequently follows other
infections, especially those of the upper respiratory tract such as a streptococcal
infection. Glomerulonephritis usually occurs in children about one to four weeks after a
streptococcal infection of the throat. There is a latent period of five days to six weeks
between an infection and the onset of nephritis (inflammation of the kidneys).

b. Signs and Symptoms of Acute Glomerulonephritis. A patient with acute
glomerulonephritis may experience the following signs and symptoms:

(1)

Hypertension (high arterial blood pressure) - mild to severe from sodium

retention, water retention, or inappropriate renin release. (Renin is an enzyme released
by the kidney into the blood stream, where renin has a part in raising blood pressure
when blood pressure is low.)

(2)

Edema (swelling because of the retention of fluid)--may be mild to severe.

(3)

Hematuria (discharge of red blood cells in the urine)--resulting in smoky

or coffee-colored urine.

(4)

Albuminuria--abnormal amount of albumin excreted each day in the

urine.

(5)

Oliguria--abnormally low amount of urine excreted per day.

MD0579 3-6

Treatment of Acute Glomerulonephritis. There are two goals of treatment

of this infection: first, relief of the symptoms and second, prevention of complications.
Treatment does not require hospitalization unless oliguria, nitrogen retention, and
hypertension are present. Instead, treatment requires supportive care to include the
following:

(1) Bed rest. The patient can gradually resume activities as his symptoms

subside.

(2) Fluid and dietary sodium restrictions.

(3) Correction of electrolyte imbalances (possibly dialysis, although this is

rarely necessary).

(4) Diuretics such as metolazone or furosemide; both will reduce the

extracellular fluid overload and help control pain.

(5)

antihypertensive (an agent that reduces high blood pressure) such as

hydralazine.

(6) Antibiotics administered as needed to prevent secondary infection or

transmission of the infection to others.

NOTE:

Information regarding this infection is important to know because acute

glomerulonephritis may look like one of the treatable genitourinary diseases.

3-7. PYELONEPHRITIS

Pyelonephritis is an inflammation of the kidney pelvis and the tissue of the kidney

itself. This is a renal disease that may be either acute or chronic.

a.

Acute Pyelonephritis. This type of pyelonephritis is fairly common. It can

be treated and, if the patient continues to be checked, there probably will not be
extensive, permanent damage of the kidneys.

(1)

Etiology of acute pyelonephritis. A bacterial infection causes the

inflammation. The bacteria most commonly reach the kidney by ascending along the
lining membrane from an infection in the lower part of the urinary tract. The bacterial
infection may occur in these ways:

(a) From a congenital weakness at the junction of the bladder and the

ureters.

(b) After instrumentation such as catheterization, cystoscopy, or

urologic surgery.

MD0579 3-7

to the kidney by blood.

(d) From an inability to empty the bladder. Patients with tumors,

strictures, or benign hypertrophy cannot completely empty the bladder of urine.
Bacteria can grow in such an environment.

(2)

Incidence of acute pyelonephritis. The incidence of acute pyelonephritis

is higher in these groups of people:

(a) Pregnant women. A small percentage of pregnant women develop

bacteriuria (bacteria in the urine). If this condition is not treated, about 40 percent of
these women develop pyelonephritis.

(b) Sexually active women. There is an increase in the possibility of

bacterial contamination.

bladder, a disorder in which the bladder does not empty completely. Bacteria may,
then, grow in the urine.

(d) Individuals with other renal diseases. A person whose renal

function is not operating properly from other renal diseases has an increased risk of
developing pyelonephritis.

(3)

Signs and symptoms of acute pyelonephritis. The signs and symptoms

of pyelonephritis may be absent or obscured by an associated disease. If signs and
symptoms are present, the following are typical:

(a)

Urgency,

frequency,

and burning during urination.

(b) Urine with a fishy odor and cloudy appearance.

(d) Chills, fever (102

F or higher), nausea, and vomiting.

(e) Possible abdominal rigidity.

(f)

Protein

and

casts on urinalysis.

NOTE:

These symptoms may develop either over a few hours or over a few days.

Even without treatment, the symptoms may disappear in a few days, but there

may still be a bacterial infection. If so, the symptoms may reappear later.

MD0579 3-8

(4)

Treatment of acute pyelonephritis. Antibiotic therapy is the center of

treatment. Start treatment after the specific infecting organism has been identified from
culture and sensitivity studies of the patient's urine. Follow this treatment:

(a) Give antibiotics after urinalysis and culture and sensitivity tests

have been performed.

(b) Continue antibiotics for 10 to 14 days. Inform the patient that urine

usually becomes sterile in from 48 to 72 hours after he starts taking antibiotics.
However, stress the importance of continuing the course of treatment for the full number
of days the treatment has been prescribed.

than 2,000 ml per day. While intake of fluid is important, the patient must take care not
to consume too much fluid. Two to three liters of fluid should be the limit of fluid
consumed by the patient. Intake of more than two or three liters of fluid may decrease
the effectiveness of the antibiotics.

(d) Control fever through antipyretics (medication that reduces or

relieves fever).

(e)

Advise

rest.

NOTE:

Teach patients with a history of urinary tract infections to recognize the signs

of infection such as cloudy urine, burning on urination, frequency, and

urgency. Early recognition of signs of a possible infection means that the

patient can seek early treatment thus preventing severe infection.

Chronic Pyelonephritis. This type of pyelonephritis is a persistent infection

that can scar the kidneys and may lead to chronic renal failure. This more serious
disease is frequently seen in patients with urinary tract blockage. Persistent or repeated
bacterial infections may cause chronic pyelonephritis. This disease can be effectively
treated with antimicrobial medication. It is very important to prevent this infection.
Preventive measures include avoiding catheterization and instrumentation and
practicing good hygiene.

3-8. HYDRONEPHROSIS

Hydronephrosis is distention of the renal pelvis and calyces caused by an

accumulation of urine caused by an obstruction to the normal urine flow. The obstruction
may occur at any level in the urinary tract.

MD0579 3-9

a. Etiology of Hydronephrosis. The most common causes include the
following:

(1)

Pregnancy.

(2) An enlarged prostate.

(3) Kidney stones that have formed in the pelvis and dropped into the

ureter.

(4)

tumor

that

presses on a ureter.

(5) Scars caused by inflammation.

Signs and Symptoms of Hydronephrosis. Signs and symptoms vary with

the cause of the obstruction. Some patients experience no symptoms or slightly
decreased urine output and mild pain.

(1)

Severe signs and symptoms. Patients experiencing severe signs and

symptoms may experience:

(a) Severe, colicky renal pain or dull, flank pain radiating to the groin.

(b) Gross urinary abnormalities such as hematuria, pyuria, dysuria,

alternating oliguria and polyuria, or complete anuria.

1 Hematuria - discharge of red blood cells in the urine.

2 Pyuria - pus in the urine.

3 Dysuria - difficulty or pain in urination.

4 Oliguria - abnormally low excretion of urine.

5 Polyuria - abnormally large excretion of urine.

6 Complete anuria - no urine is excreted.

(2)

Additional signs/symptoms. Included are:

(a)

Nausea.

(b)

Vomiting.

(c)

Abdominal

fullness.

MD0579 3-10

(d) Pain on urination.

(e)

Dribbling.

(f)

Hesitancy.

NOTE:

If the obstruction is only on one side, the pain may be just on one side. That

pain will probably be in the flank area.

Treatment of Hydronephrosis. The two main goals of treatment are to

preserve renal function and prevent infection. Both goals can be achieved by surgical
removal of the obstruction. If the surgery is performed within a few weeks, before the
kidney is damaged, the patient may recover completely. If the obstruction is not
removed, the kidney may be permanently damaged.

3-9.

ACUTE RENAL FAILURE

Acute renal failure occurs when the kidneys suddenly fail to function. As a chief

organ of the excretory system, the kidney is important in the elimination of some soluble
waste products from the body, and the regulation of water and electrolyte balance in the
body. Renal failure stops these all-important functions, and disrupts the fine balance of
the body's systems. Medical treatment can usually reverse this problem. If medication
is unsuccessful, the condition may progress to end-stage renal disease, uremic
syndrome, and death.

NOTE:

Uremic syndrome is a condition that may appear in a patient who is in the late

stages of renal failure. The skin also serves as an excretory organ. When

the failed kidneys cannot excrete waste products, the skin excretes these

products. This skin excretion causes a white film to form on the skin.

Etiology of Acute Renal Failure. Three classifications of acute renal failure

are prerenal failure, intrinsic (or parenchymal) failure, and postrenal failure.

(1)

Prerenal failure. Diminished blood flow to the kidneys causes this type

of renal failure. The reason for the decreased blood flow may be any of the following:

(a)

Hypovolemia.

(b)

Shock.

(c)

Abdominal

fullness.

(d)

Blood

loss.

(e)

Sepsis.

MD0579 3-11

(f)

Pooling of fluid in ascites or burns.

(g) Cardiovascular disorders such as congestive heart failure and

dysrhythmias.

(2)

Intrinsic (parenchymal) renal failure. This type of renal failure is caused

by damage to the kidneys themselves, the damage usually resulting from acute tubular
necrosis. Possible causes of such damage include:

(a)

Sickle-cell

disease.

(b)

Acute

post-streptococcal glomerulonephritis.

(c)

Acute

pyelonephritis.

(d) Ischemia (lack of blood in the kidneys).

(3)

Postrenal failure. Obstruction of urinary flow bilaterally causes this type

of renal failure. Possible causes of obstruction include:

(a)

Kidney

stones.

(b)

Blood

clots.

(d)

Tumors.

(e)

Urethral

edema

from catheterization.

b. Signs and Symptoms of Acute Renal Failure. Early signs of renal failure
become more severe if the kidneys do not begin functioning again. The renal failure
soon disrupts other body systems. Note the signs and symptoms in the following body
systems:

(1)

Gastrointestinal system. - Anorexia, nausea, vomiting, diarrhea or

constipation, stomatitis, bleeding, hematemesis, dry mucous members, uremic breath.

(2)

Central nervous system. - Headache, drowsiness, irritability, confusion,

peripheral neuropathy, convulsions, coma.

(3)

Integumentary system. The cutaneous skin layer has these

characteristics: dryness, pruritus, pallor, purpura, and, rarely, uremic frost.

MD0579 3-12

(4)

Cardiovascular system. An early symptom is hypotension. Later, these

signs and symptoms occur: hypertension, dysrhythmias, fluid overload, congestive heart
failure, systemic edema, and anemia.

(5)

Respiratory system.--Deep or rapid respirations caused by metabolic

acidosis and, occasionally, pulmonary edema.

c.

Most Commonly Seen Signs and Symptoms of Acute Renal Failure. As

a 91W30, you are most likely to see these signs and symptoms of renal failure:

(1) Mental disturbances such as confusion, lethargy, and stupor.

(2) Less than 30 cc an hour urine output despite replacement.

(3)

Respiratory

conditions

such as respiratory muscle paralysis.

(4) Cardiac problems such as tachycardia and dysrhythmias.

(5) Fever and chills.

Treatment of Acute Renal Failure. Treatment for acute renal failure in the

Intensive Care Unit consists of the following:

(1) Initiate an IV of 0.9 percent normal saline.

(2) Check urinary output hourly.

(3) Restrict 24-hour fluid intake.

(4)

medications.

(5) Possible hemodialysis (removal of waste materials/poisons from the

blood by means of a hemodialyzer, a piece of equipment commonly called an artificial
kidney).

3-10. CHRONIC RENAL FAILURE

Chronic renal failure, usually the end result of a gradually progressive loss of

renal function, is caused by the gradual loss of nephrons. As more and more nephrons
are destroyed, the kidneys gradually lose the ability to perform their normal functions.
Without treatment, uremic toxins can accumulate and cause potentially fatal physiologic
changes in all the major organ systems of the body.

MD0579 3-13

Etiology of Chronic Renal Failure. The causes of chronic renal failure

include:

(1) Chronic glomerular disease such as glomerulonephritis.

(2) Chronic infections such as tuberculosis.

(3) Vascular diseases such as hypertension.

(4) Obstructive processes such as calculi.

(5) Collagen diseases such as systemic lupus erythematosus.

(6) Endocrine diseases such as diabetic neuropathy.

b. Signs and Symptoms of Chronic Renal Failure. Characteristic signs and
symptoms of chronic renal failure include:

(1) Dehydration - excessive loss of body fluid. Dehydration may occur early

in renal failure when the kidneys cannot concentrate the urine and large amounts of
water are eliminated.

(2) Edema - accumulation of fluid in the tissue spaces. This condition may

occur late in chronic renal diseases when the kidneys cannot eliminate water in
adequate amounts.

(3) Hypertension - high arterial blood pressure. Hypertension may occur as

the result of fluid overload and the increased production of renin.

(4) Anemia - below normal concentration of hemoglobin in the blood for the

patient's age and sex. This condition occurs when the kidneys cannot produce the
hormone to activate the production of red bone marrow cells.

(5) Uremia - if levels of nitrogen waste products in the blood are very high,

urea can be changed into ammonia in the stomach and intestine, causing ulcerations
and bleeding.

MD0579 3-14

Treatment of Chronic Renal Failure. There are three basic elements in the

goal of medical management of a patient with chronic renal failure. First, maintain the
patient's normal body fluid volume and electrolyte balance. Second, reduce the
breakdown of tissue in the patient's body. And, third, try to prevent infection until
healing occurs. To accomplish all this, a variety of measures are used, including
restricting the patient's fluids to 400 ml per day for the average adult. Also included in
the management plan are the following:

(1) Adjustment of the patient's diet to limit the sources of nitrogen,

potassium, phosphate, and sulfate.

(2) Vigorous treatment of infection with antibiotics.

(3)

Treatment

anemia with a transfusion of a small volume of packed,

fresh red blood cells.

3-11. RENAL TUMORS

Tumors of the kidneys usually grow rather slowly. Occasionally, rapidly invading

types of tumors are found. Signs of a renal tumor include blood in the urine and dull
pain in the kidney region. Immediate surgery may be necessary to save the patient's
life.

3-12. POLYCYSTIC KIDNEY

Polycystic kidney disease is an inherited disorder. The disease runs in families.

As the name suggests, multiple, bilateral, grapelike clusters of cysts filled with fluid grow
in the kidneys. These cysts cause the kidneys to enlarge, compress the kidney tissue,
and finally squeeze functioning kidney tissue so that it cannot function any longer. The
disease may progress slowly in adults. While polycystic kidney disease cannot be
cured, life may be prolonged if associated urinary tract infections and secondary
hypertension are controlled.

3-13. RENAL CALCULI (KIDNEY STONES)

Renal calculi, more commonly known as kidney stones, are another disorder of

the genitourinary system. Substances such as calcium oxalate, calcium phosphate,
magnesium ammonium phosphate sometimes separate from the rest of the urine
solution and form a solid deposit. These formations can occur anywhere in the urinary
tract, but they usually develop in the renal pelvis or the calyces of the kidneys. There
may be one kidney stone or several. The size of the stones vary. Kidney stones
develop in Americans in the ration of 1 to 1,000 people. More common in men than
women, and rare in children and Blacks, renal calculi occur more frequently in people
who live in certain geographic areas: for instance, the Southeastern part of the United
States. The reason may be that the hot climate causes the people to become
dehydrated, or perhaps the cause is the diet of people in that part of the United States.

MD0579 3-15

Etiology of Renal Calculi. The exact cause of kidney stones is unknown,

but predisposing factors include the following:

(1)

Dehydration. Production of smaller amounts of urine promotes kidney

stones. Less liquid concentrates calculus-forming substances.

(2)

Infection. Clumps of bacteria, particularly when stasis or obstruction

accompanies infection, can serve as a nucleus for calculus formation. Additionally,
infected and damaged tissue serves as a site for calculus development.

(3)

Obstruction. Components of calculus can collect and adhere, forming

calculi (stones) in a patient with urinary stasis; for example, an immobile person with a
spinal cord injury. An obstruction also promotes infection with an even greater chance
of calculus formation.

(4)

Metabolic factors. Certain metabolic factors may predispose the

formation of calculi. Included are hyperparathyroidism, renal tubular acidosis, elevated
uric acid (usually with gout), defective metabolism of oxalate, genetic defect in the
metabolism of cystine, and excessive intake of vitamin D or dietary calcium. Excessive
intake of milk and cheese products can result in too much dietary calcium.

b. Signs and Symptoms of Renal Calculi. The signs and symptoms vary with
the size, location, and cause of the calculi. Included are the following:

(1) Pain, the key symptom, will be excruciating and intermittent, usually

originating in the flank and radiating across the abdomen, and along the course of the
ureters into that area of the groin. A stone in the kidney will cause a dull ache in the
flanks with pain extending along the rib margin toward the umbilicus. A stone in the
ureter causes pain to radiate from the costovertebral angle down the course of the
ureter to the scrotum, or vulva to the inner thighs. A stone in the bladder causes pain to
radiate to the distal urethra. This pain accompanies micturition (urination).

(2) Chills, fever, and frequent urination are common.

(3) Hematuria, the discharge of red blood cells in the urine, is common.

(4) Pyuria, with or without bacteria, may be present. Pyuria is the presence

of pus in the urine.

(5) As a ureter stone is passed into the bladder, the patient will exhibit a

stab of pain followed by instant relief. If the stone is passed with urine, it is necessary to
attempt to retrieve it so that it may be analyzed.

MD0579 3-16

Treatment of Renal Calculi. Treatment usually consists of measures to

cause renal calculi to pass through and out of the system naturally since 90 percent of
these stones are five millimeters in diameter. Additional treatment includes the
following:

(1) Hydration - encourage the patient to drink plenty of fluids.

(2) Pain control - give meperidine (Demerol

) or morphine.

(3)

DO NOT give antispasmodics.

(4) Bedrest and supportive treatment.

NOTE:

If the calculi are too large to pass through the system naturally, it may be

necessary to remove then surgically.

(5) Dietary information - a patient should be taught and urged to follow a

diet which will prevent the formation of renal calculi in the future.

Section III. MANAGEMENT OF KIDNEY DISEASES

3-14. DIALYSIS

a.

General Information.

(1) Properly functioning kidneys are vital to life. Remember the main

functions of the kidneys: maintenance of electrolyte and water balance and excretion of
waste products. If the kidneys do not function properly, waste products (such as excess
minerals, urea, toxins, and drugs) start to accumulate in the body. These waste
products must be removed for the person to continue to live. Dialysis is a technique
used to remove waste products from the blood and excess fluids from the body when
the kidneys are not functioning normally.

(2) Dialysis is the diffusion of dissolved molecules through a semipermeable

membrane. These molecules tend to pass from an area of greater concentration to an
area of less concentration. In patients who have defective kidney function, the
accumulation of urea and other nitrogen waste products can be reduced by passing the
patient's blood through a dialysis machine. Thus, dialysis removes waste products from
the bloodstream and restores the patient's electrolyte balance. Dialysis cannot cure
renal failure, but dialysis can accomplish some of the renal functions so that the patient
continues to live. A patient on dialysis uses either a machine with a semipermeable
filtering membrane, or his own peritoneal membrane to cleanse his blood.

MD0579 3-17

b. Methods of Dialysis. Two methods of dialysis presently in use are
hemodialysis and peritoneal dialysis. Both methods are based on the principle of
diffusion of dissolved molecules through a semipermeable membrane.

(1)

Hemodialysis. In this method, a sheet of cellophane functions as the

semipermeable membrane in the dialyzer machine. A patient using this method must
usually have dialysis two or three times a week. The process is as follows:

(a) Blood leaves the body through an artery.

(b) This arterial blood passes through the machine's blood pump.

(d) Blood passes through the dialyzer machine.

(e) The blood passes into the venous blood line.

(f)

Blood is filtered again to remove any clots.

(g) The blood then flows through an air detector.

(h) Finally, the blood returns to the patient through the venous blood

line.

(2)

Peritoneal dialysis. In this method of dialysis, the peritoneum acts as the

filtering membrane. Dialyzing fluid is introduced into the peritoneal cavity at intervals.
The peritoneum is a large surface area and acts as the diffusing membrane filtering the
blood in the peritoneal blood vessels. The dialyzing solution remains in the peritoneal
cavity for 15 to 30 minutes. Then the solution is allowed to drain out. The severity of
the patient's condition determines the length of time the dialysis process takes. Time
varies from 12 to 36 hours. Those patients with chronic renal disease can learn how to
do their own dialysis treatments at home. This permits patients to resume most of their
normal activities.

MD0579 3-18

3-15. KIDNEY TRANSPLANTS

A possible solution for a patient with very limited renal function is to have a

healthy kidney transplanted into his body. Many hundreds of kidney transplants have
been performed successfully during the last several years. The transplant kidney must
be from a donor whose tissue is compatible with the patient's tissue. Records show that
the likelihood that a transplant will be successful is greatest when a living donor who is
closely related to the patient is used. However, organs from deceased donors have
proven satisfactory in many cases. The problem of the patient's body rejecting the
transplanted kidney is still a major difficulty. Extensive tissue cross-matching is done,
and immune-supressing drugs are used to try to avoid problems with the transplanted
kidney. If the patient's body rejects the transplanted kidney, he will have to return to
dialysis therapy.

NOTE:

Individuals can usually do well with only one kidney. The reason is that the

kidneys have a great deal of extra functioning tissue.

Section IV. DISORDERS OF THE URETERS

3-16. URETER ABNORMALITIES/OBSTRUCTIONS

Abnormalities in structure of the ureter include double portions at the kidney

pelvis and constricted or abnormally narrow parts called strictures. Narrowing of the
ureter, another abnormality, may be caused by abnormal pressure from tumors or other
masses outside the ureter. Ureters may be obstructed by stones from the kidneys. If a
small stone moves through the ureter, the patient will experience excruciating pain.
Ptosis of the kidney (the kidney dropping) can cause the ureter tube to kink.

3-17. TREATMENT OF STONES IN THE URETERS

a.

Early Treatment. Early treatment for stones in the ureters was by "barber

surgeons" who removed stones in the ureters, operating without anesthesia. These
surgeons cut through the patient's skin and muscles of the back to remove stones from
the ureters. Termed "cutting for stone," this method was relatively successful even
though there was no sterile technique. The reason was because by approaching the
stones through the back, the peritoneal cavity was avoided, thus reducing the risk of
deadly peritonitis.

b.

Present Day Treatment. Modern surgery uses a variety of instruments for

removal of stones from the ureter, including endoscopes. Stones in the ureter are
removed by the transurethral route. That is, removal is through the urethra and the
urinary bladder from the ureter. Entrance through the skin and muscles of the back may
be used to remove calculi from the kidney pelvis or from a ureter.

MD0579 3-19

Section V. DISORDERS INVOLVING THE BLADDER

3-18. GENERAL INFORMATION

a. Injury to the bladder is uncommon; nevertheless, it may occur. A full bladder

lies in an unprotected position in the lower abdomen. A blow to the lower abdomen can
rupture the bladder, making immediate surgical repair necessary. Such injury typically
occurs in traffic accidents.

b. Another type of injury that may cause bladder disorders is injury to the spinal

cord. Injury to the spinal cord may severely disrupt bladder filling and emptying.
The most common causes of such injuries are motorcycle accidents, automobile
accidents, and bullet wounds. If the nerves controlling the bladder are damaged in such
injuries, the result may be either incontinence or urinary retention.

3-19. CYSTITIS

a.

Definition/Signs/Symptoms of Cystitis. Inflammation of the bladder, called

cystitis, is ten times as frequent in women as in men. Part of the reason may be that
the female urethra is very short compared to the urethra of the male. Bacteria (for
example, colon bacilli) ascend from the outside through the urethra into the bladder
causing cystitis. The most common symptoms of cystitis are pain, urgency (a feeling of
needing to void although the bladder is not full), and frequency of urination.

b.

Interstitial Cystitis. Interstitial cystitis is a type of cystitis in which the tissues

below the mucosa are inflamed. Symptoms include pelvic pain with discomfort before
and after urination. This disease can be diagnosed only with the use of a cystoscope (a
kind of endoscope).

c.

Etiology of Cystitis. Causes of cystitis can be traced to the following:

(1) Bladder infection caused by the infecting organism ascending through the

urethra. Such infections are more common in females, especially after intercourse. In
males, cystitis is less common than prostatis and urethritis.

(2) Trauma from catheters, stones, or instrumentation.

(3) Inadequate bladder emptying (urinary retention, dehydration, or outlet

obstruction).

d. Signs and Symptoms of Cystitis. Included are the following:

(1) Frequent, burning, urgency to urinate even when the bladder is not full.

(2) Cloudy urine caused by the presence of bacteria in the urine.

MD0579 3-20

(3) With a severe infection, chills, fever, nausea, vomiting, and abdominal or

low back pain.

(4) Occasionally, no symptoms at all.

Treatment of Cystitis. Included are the following:

(1) Urinalysis with culture and sensitivity test, if available.

(2) Systemic treatment with antibacterials such as Macrodantin

and

Mandelamine

(3) Application of heat locally.

(4) Analgesics and antispasmodics for spasms of smooth muscles of the

urinary tract.

NOTE:

Cystitis (as well as diabetes) may develop in a person whose resistance to

infection is low. The danger in cystitis is that this infection may ascend to

other parts of the urinary tract.

3-20. TUMORS OF THE BLADDER

a.

Etiology of Tumors of the Bladder. The most prevalent tumors in males

over 50 are bladder tumors. They are more common than benign papillomas and
various kinds of cancer. About 90 percent of bladder tumors arise from the epithelial
lining. Possible causes include:

(1) Toxins, particularly certain aniline dyes. (Many aniline dyes are obtained

from coal tar.)

(2) Chronic infestations of schistosomes (blood flukes) in the bladder.

(3) Heavy cigarette smoking.

(4) The presence of urinary stones. These may develop and increase in

size within the bladder.

MD0579 3-21

Signs and Symptoms of Tumors of the Bladder. Included are the

following:

(1) Hematuria (discharge of red blood cells in the urine) is the most common

symptom, occurring early in the tumor's growth.

(2) Cystitis with frequency, urgency, and pain on urination.

(3) Pain above the pubic arch, occurring as the tumor extends beyond the

bladder.

c.

Treatment of Tumors of the Bladder. Cystoscopic examination and

biopsies should be done as soon as blood is detected in the urine. Removal of the
tumor before it invades the muscle wall gives the best prognosis.

Section VI. DISORDERS OF THE URETHRA

3-21. CONGENITAL DEFECTS

A variety of congenital defects present at birth may involve the urethra as well as

other parts of the urinary tract.

a. The opening of the urethra to the outside may be too small or the urethra

itself may be narrowed.

b. Occasionally, an abnormal valve-like structure is located at the point at which
the urethra enters the bladder. If this structure is not removed surgically, these
valve-like folds of tissue can cause a backpressure of the urine with serious
consequences.

c. Occasionally, an abnormal valve-like structure is located at the point at which

the urethra enters the bladder. If this structure is not removed surgically, these
valve-like folds of tissue can cause a backpressure of the urine with serious
consequences.

3-22. OTHER DISORDERS

Other disorders to the urethra include:

Urethritis. Urethritis is the inflammation of the mucous membrane and the

glands of the urethra. This disorder is more common in males than in females. Signs
and symptoms include burning pain on urination, frequent urination, and pain in the
lower abdominal area. Urine may be cloudy, foul smelling, or dark. Urethritis is often caused by
gonorrhea, although other bacteria may also be responsible for the infection.

MD0579 3-22

b. "Straddle Injuries." These injuries to the urethra are common in men. The
urethra is caught between a hard surface and the pubic arch. This may result in rupture
of the urethra.

c.

Trauma. In accidents in which the bones of the pelvis are fractured, rupture

of the urethra is fairly common. The male urethra, especially, is easily injured in
accidents. In these cases, surgical repair of the urethra may be necessary.

Section VII. INJURIES TO ORGANS OF THE GENITOURINARY SYSTEM

3-23. GENERAL INFORMATION

Injuries to the organs of the genitourinary system can be caused by penetrating

or perforating wounds, blunt crushing accidents, and surgery. To preserve renal
function, it is very important that these injuries are diagnosed and treated promptly.

3-24. KIDNEY INJURIES

Kidney injuries can be caused by bleeding from the renal vein or arteries. The

initial cause of the bleeding may have been a blunt injury to the flank.

a.

Specific Causes/Signs/Symptoms of Kidney Injuries. Included are the

following:

(1) Wounds to the lower back in the flanks (flank = side of the body between

the ribs and the pelvis).

(2) A history of blows to the flank, hard enough to cause pain.

(3) Hematuria (discharge of red blood cells in the urine) or ecchymosis

(bruises) of the flank.

b.

Treatment for Kidney Injuries. Follow this procedure:

(1)

Start

IV.

(2) Treat the patient for shock.

(3) Obtain baseline kidney laboratory data such as a complete blood count

(CBC differential), urinalysis, urinalysis blood urea nitrogen (BUN) lytes, and urine lytes.

MD0579 3-23

3-25. BLADDER INJURIES

Bladder injuries may be caused by blunt or penetrating trauma such as seat belt

injury or fractured pelvis.

a.

Signs and Symptoms of Bladder Injuries. Included are the following:

(1) Hematuria (discharge of red blood cells in the urine).

(2) Ecchymosis (bruise) around the pubis or across the lower abdomen.

Treatment for Bladder Injuries. The treatment for bladder injuries is based

on having the bladder rest. The bladder can rest if:

(1) Catheter drainage is performed.

(2) Shock is treated, if indicated.

(3) Surgical repair is done, if necessary.

(4) Other conditions are treated; for example, a fractured pelvis is splinted

or surgically treated.

3-26. URETHRAL INJURY

The cause of urethral injury can be traced to pelvic fracture and penetrating

wounds to the groin.

a.

Signs and Symptoms of Urethral Injury. Included are the following:

(1)

Hematuria.

(2) Escape of urine and blood into the surrounding tissues in the lower

groin.

b.

Treatment of Urethral Injury. Treat as follows:

(1) Attempt to insert a Foley catheter without forcing.

(2) Treat any wounds of the external genitalia.

MD0579 3-24

Section VIII. DRUG THERAPY FOR GENITOURINARY DISEASE/DISORDERS

3-27. DRUG THERAPY

A number of medications can be given to treat genitourinary system diseases

and disorders. Information about some of these medications is given here. The
medications are sulfisoxazole, trimethoprim, cotrimoxazole sulfamethoxazole, ampicillin,
tetracycline, nitroufurantoin, methenamine mandelate, and phenazopyridine.

3-28. SULFISOXAZOLE (GANTRISIN

)

Sulfisoxazole is an antibacterial agent used in drug therapy for genitourinary

disease and disorders. Sulfonamides are very effective in treating a wide variety of
first-time infections. The dosage for sulfisoxazole is a loading dose of gm by mouth,
followed by 1-2 gm by mouth four times a day for a period of 10 to 14 days.

a.

Adverse Reactions to Sulfisoxazole. Included are the following:

(1) Nausea and vomiting.

(2) Pain, arthralgia, joint pain.

(3)

Crystalluria

(presence

of crystals in the urine).

(4)

Renal

damage.

(5)

Liver

damage.

(6) Serious blood dyscrasias (general morbid condition of the blood).

Contraindications for Sulfisoxazole. Generally, sulfonamides are

contraindicated for recurrent and chronic urinary tract infections. These drugs are not
recommended for long-time use because they alter fecal flora thus increasing the risk of
resistant infection. Sulfonamides should be avoided in the following patients:

(1) Pregnant women at term and nursing mothers. (This drug passes

through the placenta and is excreted in the milk.)

(2)

Individuals

with

impaired renal or hepatic function.

(3) Patients with hemolytic anemia (anemia from abnormal destruction of

red blood cells in the body).

MD0579 3-25

(4)

Individuals

hypersensitive to sulfonamides.

NOTE:

When sulfonamides are used, it is necessary for the patient to maintain an

adequate fluid intake in order to avoid crystalluria (the presence of crystals in

the

urine).

3-29. TRIMETHOPRIM AND COTRIMOXAZOLE SULFAMETHOXAZOLE
(BACTRIM

, SEPTRA

)

Either of these medications may be indicated for the treatment of chronic urinary

tract infections evidenced by persistent bacteria, frequent recurrent infections or
infections associated with urinary tract complications such as obstruction. The dosage
of trimethroprim and cotrimoxazole is 800 mg twice a day for 10 to 14 days. DO NOT
USE these medications with patients with hepatic and renal dysfunction if the patients
have adverse reactions to these medications. Contraindications are the same as for the
medication Gantrisin

(paragraph 3-28a).

3-30. AMPICILLIN (PENBRITIN

, POLYCILLIN

, OMNIPEN

)

These are clinically indicated, broad-spectrum antibiotics that are effective in

treating genitourinary infections. The dosage of an ampicillin drug is 25 to 500 mg
every six hours for 10 to 14 days. Adverse reactions to ampicillin are limited to
sensitivity phenomena. The contraindications of this drug are those known individuals
who are sensitive to penicillin.

3-31. TETRACYCLINE (CYCLOPAR

)

This broad-spectrum antibiotic is effective against gram-positive and negative

bacteria, certain mycoplasma, rickettsiae, and protozoa. The dosage is 250 mg by
mouth every six hours for 10 to 14 days.

a.

Adverse Reactions to Tetracycline. Adverse reactions to this drug include

the following:

(1)

Gastrointestinal

disturbance.

(2)

Skin

rash.

(3)

Renal

toxicity.

(4) Hypersensitivity to the drug.

Contraindications to Tetracycline. Contraindications are those known to

patients who have tetracycline hypersensitivity. Use of this drug should be watched
during pregnancy. The drug may cause discoloration of the teeth, enamel hypoplasia
(failure of the enamel of the teeth to develop completely), and bone growth inhibition.

MD0579 3-26

3-32. NITROUFURANTOIN (MACRODANTIN

)

This drug, a synthetic antibacterial agent, is used as a short-time preventive

measure and also in long-term suppressive therapy for individuals with chronic urinary
tract infections. The dosage of this drug is 5 to 100 mg four times a day for a three-day
period. After this period, the urine is sterile. This medication is a urinary antiseptic.
That is, nitroufurantoin is an agent that kills or prevents the growth of microorganisms
when applied to living tissue.

a.

Possible Adverse Reactions. Included are the following:

(1)

Gastric disturbances. The patient may experience nausea, vomiting,

and diarrhea. To lower gastric irritation, give the medication with milk. The severity of
the reaction is related to the strength of the medication dose.

(2)

Hypersensitivity reactions. The patient may experience pulmonary

pneumonitis. Signs and symptoms of this condition may disappear when the drug is
discontinued.

b.

Contraindications to Nitrofurantoin. Included are the following:

(1) Anuria (patient of average adult size voids less than 100 ml of urine

daily).

(2)

Oliguria.

(3)

Renal

impairment.

(4)

Pregnancy.

(5) Infants of less than one month.

(6) Known sensitivity to nitrofurantoin.

3-33. METHENAMINE MANDELATE (MANDELAMINE

)

This drug is clinically indicated as a prophylactic and suppressive treatment of

bacteriuria via urine acidification. The dosage of this drug is 1 gm four times a day for
three days after the urine is sterile. Adverse reactions to the drug include the following:

a. Mild gastric irritation.

b. Inflammation of the urinary tract in higher doses.

c. Hypersensitivity reaction such as a rash.

MD0579 3-27

NOTE:

DO NOT give this drug to a patient is who is taking Bactrim

or Septra

Methenamine works best in an acidic urine. If sulfonamides are administered

at the same time, a precipitate will form caused by the basic nature of the

sulfonamides.

3-34. PHENAZOPYRIDINE (PYRIDIUM

)

Phenazopyridine is an analgesic (an agent to relieve pain). This medication is

clinically indicated for pain associated with urinary tract irritation or infection. The
medication is excreted in the urine where it acts as a local anesthetic on mucosa. This
drug helps relieve the patient of pain and burning during urination. Also relieved is the
patient's feeling of needing to urinate too frequently and urgently. The recommended
dosage for adults is 100 to 200 mg by mouth four times a day after meals for three
days, if the pain is relieved. The drug may alter clinistix or Tes-tape results. Clinitest
tabs must be used if urinalysis is needed. Adverse reactions to this medication include:

a.

Headache.

Rash.

Pruritus.

d. Occasional gastrointestinal disturbances.

e. Staining of contact lenses has been reported.

f. At overdose levels, hemolytic anemia (anemia from abnormal destruction of

red blood cells in the body) and renal and hepatic toxicity.

NOTE:

Warn patients that this drug will color the urine red to orange and can stain

fabrics.

Section IX. THE EFFECTS OF AGING

3-35. GENERAL INFORMATION

A number of biologic changes that are influenced by hereditary and

environmental factors occur in the aging. Some changes are physiologic, changes that
occur because of normal wear and tear over the years. Other changes are the result of
disease or the person's life-style. It is important to remember that each individual ages
in his own unique way. This accounts for the wide variation of changes in the aging
population.

MD0579 3-28

3-36. GENITOURINARY SYSTEM CHANGES

A number of changes in the genitourinary system occur as the body ages. Look

at these changes.

a. Even without kidney disease, aging causes the kidneys to lose some of their

ability to concentrate urine. With aging, progressively more water is needed to excrete
the same amount of waste. Therefore, it is necessary for older persons to drink more
water than young people. Older people eliminate larger amounts of urine (polyuria)
even at night (nocturia).

b. Beginning at about age 40, there is a decrease in the number and size of the

nephrons. Often, more than 50 percent of the nephrons are lost before age 80.

c. There may be an increase in blood urea nitrogen (BUN) without serious

symptoms.

d. The elderly are more susceptible than young people to infections of the

urinary system.

e. Childbearing may have caused damage to the musculature of the pelvic floor.

Years later, this damage may cause urinary tract problems.

f.

Enlargement

the

prostate, common in older men, may cause obstruction

and back pressure in the ureters and kidneys. If an enlarged prostate condition is
untreated, it will cause permanent damage to the kidneys.

g. Age changes may predispose a person to incontinence, but age changes do

not cause a person to be incontinent. Most elderly persons (60 percent of those
residing in nursing homes and up to 90 percent of those living independently) have no
incontinence.

3-37. CLOSING

All the systems of the body are important. The body has developed the ability to

protect itself by being able to compensate and function well with only one kidney.
Looking at that compensatory mechanism, it is even more devastating when kidney
failure occurs, and the person must rely on dialysis. Early awareness of such problems
can eliminate or prevent many diseases, which attack the kidneys. An individual can
survive without a bladder, but the quality of life will be drastically changed. Use your
assessment skills to obtain early treatment for diseases of the genitourinary system,
preventing those diseases from progressing to more serious levels.

Continue with Exercises

MD0579 3-29

EXERCISES, LESSON 3

INSTRUCTIONS. Answer the following exercises by writing the answer in the space
provided.

After you have completed all of these exercises, turn to "Solutions to Exercises" at the
end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1. Urinary tract infections are caused by __________________________________.

They are located anywhere between the _______________________________

and the _______________________________________________________.

2. List four factors that predispose an individual to urinary tract infections.

a.

__________________________________________________________.

3. The term neurogenic bladder is used to refer to any _____________________

______________________________________________________________.

4. The primary symptom of a urinary tract infection is ______________________.

5. Laboratory analysis of urine indicates the following:

a. Pale urine indicates ____________________________________________.

b. Greenish urine indicates ________________________________________,

c. Brown-black urine indicates _____________________________________

or __________________________________________________________.

MD0579 3-30

6. Glomerulonephritis is an inflammation of the kidneys in which antibodies formed

in response to streptococci attach themselves to the

____________________________________________________________.

7. List three signs/symptoms of acute glomerulonephritis.

a.

__________________________________________________________.

8. Pyelonephritis is an inflammation of the _____________________________

_____________________________________________________________.

9. List four groups of people in which the incidence of acute pyelonephritis is high.

a.

__________________________________________________________.

10. A patient with acute pyelonephritis should encouraged to achieve a urinary

output of more than ______________________________________________.

11. Hydronephrosis is ________________________________________________

_____________________________________________________________

caused by _______________________________________________________

_____________________________________________________________.

MD0579 3-31

12. The treatment for hydronephrosis is ______________________________

_____________________________________________________________.

13. List three types of acute renal failure and their causes.

a.

__________________________________________________________

___________________________________________________________.

__________________________________________________________

___________________________________________________________.

__________________________________________________________

___________________________________________________________.

14. The three basic elements in the goal of medical management of a patient with

chronic renal failure are:

__________________________________________________________.

15. List two signs/symptoms of renal tumors.

a.

__________________________________________________________.

16. Polycystic kidney is an inherited kidney disorder. What occurs?

_____________________________________________________________.

17. Another name for renal calculi is ______________________________________.

MD0579 3-32

18. Possible causes of renal calculi Infection are obstruction, metabolic factors, and

____________________________________________________________

19. List three signs and symptoms of renal calculi.

a.

__________________________________________________________.

20. Dialysis is diffusion of dissolved molecules through a

_____________________________________________________________.

21. What does dialysis do? ___________________________________________

_____________________________________________________________.

22. List two methods of dialysis.

a.

__________________________________________________________.

23. Cystitis is an ____________________________________________________

_____________________________________________________________.

24. Tumors of the bladder are most common in males over the age of ___________.

25. Two

signs/symptoms of cystitis are:

__________________________________________________________.

MD0579 3-33

26. List four causes of tumors of the bladder.

a.

__________________________________________________________.

27. "Straddle injuries," common in men, are caused by ____________________

_____________________________________________________________.

28. List two signs/symptoms of kidney injuries.

a.

__________________________________________________________.

29. The basic treatment for bladder injuries is to _________________________

_____________________________________________________________.

30. List two possible causes of urethral injury.

a.

__________________________________________________________.

31. Pregnant women at term should not be given Sulfisoxazole, a medication

effective in treating genitourinary disease, because ____________________

_____________________________________________________________.

MD0579 3-34

32. Tetracycline, a broad-spectrum antibiotic, may have a negative effect on teeth.

List two effects.

__________________________________________________________.

33. Phenazopyridine, an analgesic, can have an effect on contact lenses.

What is that effect? _____________________________________________

_____________________________________________________________.

34. Why should older people drink more water than young people?

___________________________________________________________

___________________________________________________________

___________________________________________________________.

Check Your Answers on Next Page

MD0579 3-35

SOLUTIONS TO EXERCISES, LESSON 3

1. Infectious organisms.
Kidneys.

Urethral opening. (para 3-2a)

2. Sex of the individual (females are at greater risk for UTIs).
Urinary

stasis.

Instrumentation.

Neurogenic bladder. (para 3-2b(1) - (4))

3. Disturbance of the bladder function caused by impairment of the nerve supply.
(para

3-2b(4))

4. Pain. (para 3-3)

5. a. Diabetes insipidus.

b. Bile pigment, which is associated with jaundice.

Poisoning

hemorrhage. (para 3-4a(6))

6. Glomerular membrane and injure this membrane. (para 3-6)

7. You are correct if you listed any three of the following:
Hypertension.
Edema.
Hematuria.
Albuminuria.

Oliguria. (para 3-6b(1) - (5))

8. Kidney pelvis and the tissue of the kidney itself. (para 3-7)

9. Pregnant women.

Sexually active women.

Diabetic

individuals.

Individuals with other renal diseases. (para 3-7a(2)(a) - (d))

10. 2,000 ml per day. (para 3-7a(4)(c))

11. Distention of the renal pelvis and calyces

An accumulation of urine caused by an obstruction to the normal urine flow.

(para

3-8)

12. Surgical removal of the obstruction. (para 3-8c)

MD0579 3-36

13. Prerenal failure is caused by diminished blood flow to the kidneys.

Intrinsic (parenchymal) renal failure is caused by damage to the kidneys

themselves, the damage usually resulting from acute tubular necrosis.

Postrenal failure is caused by obstruction of urinary flow bilaterally.

(para 3-9a(1) - (3))

14. Maintain the patient's normal body fluid volume and electrolyte balance.

Reduce the breakdown of tissue in the patient's body.

Try to prevent infection until healing occurs. (para 3-10c)

15. Blood in the urine.

Dull pain in the kidney region. (para 3 - 11)

16. Multiple, bilateral, grapelike clusters of cysts filled with fluid grow in the kidneys.
(para

3-12)

17. Kidney stones. (para 3-13)

18. Dehydration.

(para 3-13a(1)

19. You are correct if you listed any three of the following:
Pain.
Pyuria.

Chills, fever, and frequent urination are common.

Hematuria.

Stab of pain followed by instant relief. (para 3-13b(1) - (5))

20. Semipermeable

membrane. (para 3-14)

21. Dialysis removes waste products from the patient's bloodstream and restores the

patient's electrolyte balance. Basically, dialysis cleanses the patient's blood.

(para

3-14a(2))

22. Hemodialysis.

Peritoneal dialysis. (para 3-14b(1), (2))

23. Inflammation of the bladder that is ten times as frequent in women as in men.
(para

3-19a)

24. 50. (para 3-20a)

MD0579 3-37

25. You are correct if you listed any two of the following:

Frequent burning urgency to urinate (although the bladder is not full).

Chills
Nausea.
Fever.
Vomiting.

Abdominal pain.

Low back pain.

Cloudy

urine.

Occasionally, no symptoms at all. (para 3-19d(1) - (4))

26. Toxins.

Chronic infestations of schistosomes (blood flukes) in the bladder.

Heavy cigarette smoking.

Presence of urinary stones. (para 3-20a(1) - (3))

27. The urethra being caught between a hard surface and the pubic arch. (para 3-22b)

28. You are correct if you listed any two of the following:

Wounds to the lower back in the flanks

A history of blows to the flank, hard enough to cause pain.

Hematuria.

Ecchymosis. (para 3-24a(2) - (3))

29. Have the bladder rest. (para 3-25b)

30. Pelvic

fracture.

Penetrating wound to the groin. (para 3-26)

31. This drug passes through the placenta to the fetus. (para 3-28b(1))

32. You are correct if you listed any two of the following:

Discoloration of teeth.

Enamel hypoplasia (failure of the enamel of the teeth to develop completely).

Bone growth inhibition. (para 3-31b)

33. Phenazopyridine can stain contact lenses. (para 3-34e)

34. With aging, progressively more water is needed to excrete the same amount of

waste. Therefore, it is necessary for older persons to drink more water than

young people. Older people eliminate larger amounts of urine (polyuria) even at

night (nocturia). (para 3-36a)

End of Lesson 3

MD0579 3-38

LESSON ASSIGNMENT

LESSON 4

Urinary System Diseases/Disorders

LESSON ASSIGNMENT

Paragraphs 4-1 through 4-8.

LESSON OBJECTIVES

After completing this lesson, you should be able to:

4-1.

Identify the purposes of and indications for

urinary

catheterization.

4-2.

Identify the procedures for performing a urinary

catheterization.

4-3.

Identify the proper procedures for maintaining

surgical aseptic technique.

SUGGESTION

After completing the assignment, complete the

exercises at the end of this lesson. These exercises

will help you to achieve the lesson objectives.

MD0579 4-1

LESSON 4

URINARY CATHETERIZATION

4-1. INTRODUCTION

Sometimes the homeostasis of the urinary system becomes upset, making the

normal function of micturition impossible. There may be a need then for catheterization.
Health care providers must strive to make this a safe, efficient, and non-traumatic
experience for the patient.

4-2.

PURPOSES OF CATHETERIZATION

There are a number of reasons why catheterization may be performed. Included

are the following:

a. Obtain a sterile urine specimen.

b. Measure the amount of residual urine in the bladder.

c. Relieve a distended bladder in the patient who is unable to void.

Provide

continuous

drainage or irrigation.

e. Administer medications such as a chemotherapeutic solution.

f. Measure the urinary output.

g. Prepare a patient for a surgical procedure or obstetrical delivery (childbirth).

h. Assist the patient following surgery.

4-3.

INDICATIONS FOR CATHETERIZATION

Indications

for

catheterization include the following:

a. The patient's bladder is severely distended.

b. Urinary output is severely decreased.

c. There is a significant outflow obstruction.

d. The patient is in shock or pre-shock status.

e. The patient has an acute spinal cord injury.

MD0579 4-2

4-4. GENERAL

PRECAUTIONS

Because both the bladder and the urethra are easily injured and highly

susceptible to infection, it is important to remember several precautions in the
performance of this procedure.

a. Aseptic Technique. Aseptic technique is essential. Each catheterization is
a potential source of infection if not carried out properly. Most cases of cystitis that
develop after catheterization are caused by improper catheterization technique. Cystitis is
difficult to cure and causes increased pain for the patient.

b.

Lubricated Catheter. The catheter must be well lubricated (unless made of

silicone) prior to insertion. Lubrication reduces friction and trauma to the mucous
membrane lining of the urethra and the bladder.

c.

Principles of Insertion. The catheter is inserted only far enough to enter the

bladder. Since the adult male urethra is usually about six inches long, it is usually
sufficient to insert the catheter about seven inches. The female urethra is about 1 and
one half inches long, extending from the bladder to an external opening between the
clitoris and the opening of the vagina. A two-inch insertion of the catheter should suffice
in the adult female.

d.

Skillful Handling of Equipment. A medical specialist who is skillful in

handling the equipment can avoid trauma to the patient by being gentle. Use only mild
pressure. Never force a catheter into place. If more than normal resistance is met,
report the difficulty to the doctor. In these cases, which are unusual, dilation
(expansion) of the urethra may be necessary.

4-5. CATHETERIZATION

PROCEDURE

Follow this procedure.

a. Check the doctor's orders.

b. Gather equipment. Assemble this equipment:

(1) Catheter, in the appropriate size (the size you ordered).

(2)

Drainage

bag.

(3)

Sterile

gloves.

(4) Water soluble lubricant.

(5)

Cleansing

agent.

MD0579 4-3

(6) Cotton balls or sterile 4 inch by 4 inch pads.

NOTE:

Cotton balls or 4 by 4-inch pads soaked in a cleansing agent can be used as

antiseptic

wipes.

(7)

Forceps.

(8)

Nonallergic

tap.

(9) Sterile solution to inflate balloon.

(10)

Sterile

specimen

container, if indicated.

(11)

Sterile

drapes.

(12)

Collection

basin.

NOTE:

If you are using a commercially prepared catheter set, the items shown in

figure 4-1 will be in the set.

Figure 4-1. Foley catheter set up.

MD0579 4-4

c. Explain the procedure to the patient. This procedure may be embarrassing to

the patient and cause him some anxiety. It is, therefore, very important to explain to the
patient what you are going to do. Tell the patient that the procedure will not be painful
but that he will feel pressure as the catheter is inserted.

d. Provide for the patient's privacy. Provide privacy by drawing curtains around

an area or closing a hall door.

e.

Wash

your

hands.

f. Do these pre-performance steps.

(1) Move the patient to the side of the bed nearest you. Raise the bed to

working height to avoid back strain while you are working. Lower the side rail, if
necessary, on the side where you are working.

(2) Position the patient. Help the patient into the dorsal recumbent position

(patient on his back with his lower limbs flexed and rotated outward).

(3)

Insertion

technique

for an indwelling catheter.

(a) Remove the drainage system from the bag.

(b) Attach the bag to the bed frame.

the mattress.

(d) Place the end of the drainage tubing so that it is convenient to

reach and won't fall off the mattress during the procedure.

NOTE:

These steps are not performed when a commercial pack is used.

(4) Open the sterile catheter tray.

(5) Don sterile gloves.

(6) Pick up the plastic-coated drape.

(7) Grasping the drape at the top (with the plastic side away from you), fold

the of the drape over your gloved hands to make a cuff.

(8) Place the drape, with the plastic side down, on the bed between the

patient's legs. Slip the cuffed edge under the patient's buttocks. Pull your hands out.

MD0579 4-5

(9) If desired, pick up the fenestrated drape and place it over the patient's

genitalia.

(10) Place a sterile tray on the sterile drape between the patient's legs.

(11)

If you are obtaining a specimen, remove the lid from the specimen

container and place the lid on the sterile drape.

(12) Squeeze a small amount of sterile lubricant into the catheter tray.

(13)

If you are inserting an indwelling catheter, attach the filled syringe to the

lumen valve of the catheter. Check the balloon patency.

(14)

Prepare

antiseptic cleansing solution.

(15) Cleanse the patient. Cleansing the area properly is very important in

order to prevent infection. Urinary catheterization is responsible for a high percentage
of nosocomial infections. (Nosocomial infection = infection acquired in a treatment
facility.)

(a) Cleansing a female patient.

1 Separate the labia with your nondominant hand.

2 Place the thumb and forefinger between the labia minoria.

3 Separate the labia and pull up.

4 With your dominant hand using the forceps to hand antiseptic

wipes, cleanse the far labia from the clitoris toward the anus with the wipe. Discard the
used wipe.

5 With another wipe, cleanse the near labia. Discard that used

wipe.

6 With another wipe, cleanse down the center directly over the

meatus. Discard the used wipe.

7 Throughout the procedure, keep the labia spread.

(b) Cleansing a male patient.

1 Support the penis with your nondominant hand.

MD0579 4-6

2 Using forceps to handle the antiseptic wipes, cleanse the penis

in a circular motion from the meatus toward the base of the penis. Discard the used
wipe.

3 Repeat this process at least twice.

g. Insert a catheter in a female. See figure 4-2.

(1) Pick up the catheter with your dominant hand. Hold the catheter about

three inches from its tip.

(2) Lubricate the tip of the catheter. Keep the remainder of the catheter

coiled into the palm of your hand.

(3) Ask the patient to breathe through her mouth.

(4) Gently insert the catheter (downward and toward the back) about two

inches or until urine begins to flow. DO NOT insert the catheter more than two inches.

(5) Release the labia and hold the catheter securely with your nondominant

hand.

(6) If the vagina is inadvertently catheterized, DO NOT reuse the catheter.

Assemble fresh equipment and attempt the procedure again.

Figure 4-2. Female catheterization.

MD0579 4-7

h. Insert a catheter in a male. Catheterization of a male differs from a female

primarily in positioning and cleansing. The tray and equipment are the same. The
principles of aseptic technique must be maintained. The preparation of materials to be
taken to the patient's bedside are the same. Follow the steps listed in paragraph 4-5a
through c with these exceptions: place the patient in a supine position with his legs
extended and place a moisture-proof pad across his upper thighs. See figure 4-3.
Then follow this procedure.

(1) Pick up the catheter with your dominant hand about three inches from

the tip. With your last three fingers, hold the distal end of the catheter in the palm of
your hand.

(2) Lubricate the tip of the catheter.

(3) Draw the penis upward and forward at a 60 to 90 degree angle to the

patient's legs.

(4) Have the patient breathe through his mouth.

(5) Insert the tip of the catheter into the urethra. Grasp the catheter and

gently insert seven to eight inches or until resistance is met.

(6) Gently advance the catheter until urine flows.

(7) Lower the penis and hold the catheter securely with your non-dominant

hand. Rest your hand on the patient's pubis for support.

(8) Place the other end of the catheter in the collection basin.

Figure 4-3. Male catheterization.

MD0579 4-8

4-6.

OBTAIN A SPECIMEN

If ordered to obtain a specimen, follow this procedure:

a. Place the specimen container in the collection basin.

b. Pinch the catheter with your nondominant hand.

c. Pick up the drainage end of the catheter and hold it over the specimen

container.

d. Unclamp your fingers and allow approximately 30 cc of urine to drain into the

container.

e. Re-pinch the catheter and place the drainage end into the collection basin.

f. Allow the urine flow to resume.

g. Place the specimen container on the table and replace the lid.

4-7. INDWELLING

CATHETER

An indwelling (retention) catheter is ordered to permit continued drainage of the

urinary bladder without repeated catheterization. The catheter commonly used is a
self-retaining urethral catheter (Foley type). This catheter has a double lumen, with one
opening for drainage and the other for inflation of the retention device (a small balloon
at the tip of the catheter). After insertion of an indwelling catheter, perform these steps:

a. Inflate the balloon with the proper amount of solution from the syringe.

b. Tug gently on the catheter to make sure the balloon is inflated sufficiently to

retain the catheter in place.

c. Attach drainage tubing from the collection system to the catheter without

contaminating either. (With a commercially prepared catheterization set, the catheter
comes connected to the collection system.)

d. The patient's facial expression is a good indication of whether or not balloon

was inflated within the urethra.

MD0579 4-9

4-8.

CONCLUDING STEPS OF CATHETERIZATION

a. Remove your gloves.

b. Tape the catheter to the patient. For a female, tape the catheter to the inner

aspect of the thigh. For a male, tape the catheter to the abdomen if ordered by the
doctor or tape it to the inner thigh.

c. Clean the genital area.

d. Reposition the patient. Be sure the patient is safe and comfortable.

e. Report and record the procedure.

Continue with Exercises

MD0579 4-10

EXERCISES, LESSON 4

INSTRUCTIONS. Answer the following exercises by writing the answer in the space
provided.

After you have completed all of these exercises, turn to "Solutions to Exercises" at

the end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1.

List four purposes of catheterization.

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

2.

Reducing friction and trauma to the mucous membrane lining of the urethra and

the bladder are two reasons to____________________________________

catheter

before insertion.

You meet more than normal resistance when inserting a catheter.

What should you do?

____________________________________________________________.

MD0579 4-11

When you are explaining the catheterization process to a patient,

tell him that inserting the catheter will not be _________________________,

but he will feel _________________________________________________.

as the catheter is inserted.

The first four steps in the catheterization procedure are to:

Check

____________________________________________________.

Gather

____________________________________________________.

Explain

___________________________________________________.

Provide

___________________________________________________.

Catheterization of a male differs from catheterization of a female primarily

in two ways. They are _________________________________________.

and

________________________________________________________.

After inserting a Foley catheter (an indwelling catheter), you inflate the

_____________________________________ to keep the catheter in place.

Check Your Answers on Next Page

MD0579 4-12

SOLUTIONS TO EXERCISES, LESSON 4

1.

You are correct if you listed any four of the following:

Obtain a sterile urine specimen.

Measure the amount of residual urine in the bladder.

Relieve a distended bladder in the patient who cannot void.

Provide continuous drainage or irrigation.

Administer

medications.

Measure urinary output.

Prepare a patient for surgery or childbirth.

Help a patient after surgery. (para 4-2a through h).

Lubricate catheter. (para 4-4b)

DO NOT force the catheter in place. Report the difficulty to a doctor.

(para

4-4d)

Painful.

Pressure as the catheter is inserted. (para 4-5c)

a. Check the doctor's orders.

Gather

equipment.

c. Explain the procedure to the patient.

d. Provide for the patient's privacy. (para 4-5a through d)

Positioning.

Cleansing. (para 4-5h)

Balloon. (para 4-7)

End of Lesson 4

MD0579 4-13

Document Outline

DEVELOPMENT
ADMINISTRATION
TABLE OF CONTENTS
INTRODUCTION
LESSON 1
LESSON 2
LESSON 3
LESSON 4

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